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Hager DN, Chandrashekar P, Bradsher RW, Abdel-Halim AM, Chatterjee S, Sawyer M, Brower RG, Needham DM. Intermediate care to intensive care triage: A quality improvement project to reduce mortality. J Crit Care 2017; 42:282-288. [PMID: 28810207 DOI: 10.1016/j.jcrc.2017.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/06/2017] [Accepted: 08/02/2017] [Indexed: 02/05/2023]
Abstract
PURPOSE Medical patients whose care needs exceed what is feasible on a general ward, but who do not clearly require critical care, may be admitted to an intermediate care unit (IMCU). Some IMCU patients deteriorate and require medical intensive care unit (MICU) admission. In 2012, staff in the Johns Hopkins IMCU expressed concern that patient acuity and the threshold for MICU admission were too high. Further, shared triage decision-making between residents and supervising physicians did not consistently occur. METHODS To improve our triage process, we used a 4Es quality improvement framework (engage, educate, execute, evaluate) to (1) educate residents and fellows regarding principles of triage and (2) facilitate real-time communication between MICU residents conducting triage and supervising physicians. RESULTS Among patients transferred from the IMCU to the MICU during baseline (n=83;July-December 2012) and intervention phases (n=94;July-December 2013), unadjusted mortality decreased from 34% to 21% (p=0.06). After adjusting for severity of illness, admitting diagnosis, and bed availability, the odds of death were lower during the intervention vs. baseline phase (OR 0.33; 95%CI 0.11-0.98). CONCLUSIONS Using a structured quality improvement process targeting triage education and increased resident/supervisor communication, we demonstrated reduced mortality among patients transferred from the IMCU to the MICU.
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Affiliation(s)
- David N Hager
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States.
| | - Pranav Chandrashekar
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Robert W Bradsher
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, United States.
| | - Ali M Abdel-Halim
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States.
| | - Souvik Chatterjee
- Critical Care Medicine Department, Clinical Center, National Institutes of Health Clinical Center, Bethesda, MD, United States.
| | - Melinda Sawyer
- Armstrong Institute for Patient Safety, John Hopkins University, Baltimore, MD, United States.
| | - Roy G Brower
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States.
| | - Dale M Needham
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, United States; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, United States.
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52
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0330-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
BACKGROUND Rapid response teams (RRTs) have been widely accepted as useful adjuncts to the care of inpatients with unanticipated emergencies. One study suggested that leadership of such teams could be assigned to midlevel providers, especially when nonhospitalized person (NHP)-related emergencies occur. However, in our tertiary medical center, a critical care medicine (CCM) physician always leads all RRT events including those related to NHPs. OBJECTIVE In this study, we postulate reasons in favor of a single structured RRT led by an intensivist for both inpatients and NHPs. METHODS An observational study conducted at an academic medical center. Demographic and clinical characteristics of NHP-related RRT events were evaluated over a 9-month period. MEASUREMENTS AND MAIN RESULTS Rapid response teams were activated 1,952 times, of which, 154 events were NHP related. Only 42 RRT activations occurred for employees and visitors. Most of the NHP activations (112 events) occurred in response to events involving persons who were on the premises because of preexisting illnesses, either visiting physician offices (46 events), undergoing ambulatory diagnostic procedures (30 events), in transit to the emergency department (13 events), or undergoing emergency psychiatry evaluation (11 events). Most patients (83 NHPs) required admission to the hospital including 22 NHPs to intensive care units (ICUs) either directly from the event location or subsequently from the emergency department. The physician team leader admitted 20 NHPs directly from the scene, of which, 13 were admitted directly to ICUs. CONCLUSION Nonhospitalized patients requiring RRT activation often have complex pre-existent illnesses. A standardized team composition for both inpatients and NHPs in crisis is an appropriate administrative structure enhancing patient safety in hospitals where ambulatory and inpatient facilities are combined.
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Abstract
OBJECTIVE We studied rapid response events after acute clinical instability outside ICU settings in pediatric cardiac patients. Our objective was to describe the characteristics and outcomes after rapid response events in this high-risk cohort and elucidate the cardiac conditions and risk factors associated with worse outcomes. DESIGN A retrospective single-center study was carried out over a 3-year period from July 2011 to June 2014. SETTING Referral high-volume pediatric cardiac center located within a tertiary academic pediatric hospital. PATIENTS All rapid response events that occurred during the study period were reviewed to identify rapid response events in cardiac patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We reviewed 1,906 rapid response events to identify 152 rapid response events that occurred in 127 pediatric cardiac patients. Congenital heart disease was the baseline diagnosis in 74% events (single ventricle, 28%; biventricle physiology, 46%). Seventy-four percent had a cardiac surgery before rapid response, 37% had ICU stay within previous 7 days, and acute kidney injury was noted in 41% post rapid response. Cardiac and/or pulmonary arrest occurred during rapid response in 8.5%. Overall, 81% were transferred to ICU, 22% had critical deterioration (ventilation or vasopressors within 12 hr of transfer), and 56% received such support and/or invasive procedures within 72 hours. Mortality within 30 days post event was 14%. Significant outcome associations included: single ventricle physiology-increased need for invasive procedures and mortality (adjusted odds ratio, 2.58; p = 0.02); multiple rapid response triggers-increased ICU transfer and interventions at 72 hours; critical deterioration-cardiopulmonary arrest and mortality; and acute kidney injury-cardiopulmonary arrest and need for hemodynamic support. CONCLUSIONS Congenital heart disease, previous cardiac surgery, and recent discharge from ICU were common among pediatric cardiac rapid responses. Progression to cardiopulmonary arrest during rapid response, need for ICU care, kidney injury after rapid response, and mortality were high. Single ventricle physiology was independently associated with increased mortality.
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55
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Makam AN, Nguyen OK, Clark C, Halm EA. Evaluating Automated Rules for Rapid Response System Alarm Triggers in Medical and Surgical Patients. J Hosp Med 2017; 12:317-322. [PMID: 28411289 PMCID: PMC5812482 DOI: 10.12788/jhm.2712] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The use of rapid response systems (RRS), which were designed to bring clinicians with critical care expertise to the bedside to prevent unnecessary deaths, has increased. RRS rely on accurate detection of acute deterioration events. Early warning scores (EWS) have been used for this purpose but were developed using heterogeneous populations. Predictive performance may differ in medical vs surgical patients. OBJECTIVE To evaluate the performance of published EWS in medical vs surgical patient populations. DESIGN Retrospective cohort study. SETTING Two tertiary care academic medical center hospitals in the Midwest totaling more than 1500 beds. PATIENTS All patients discharged from January to December 2011. INTERVENTION None. MEASUREMENTS Time-stamped longitudinal database of patient variables and outcomes, categorized as surgical or medical. Outcomes included unscheduled transfers to the intensive care unit, activation of the RRS, and calls for cardiorespiratory resuscitation ("resuscitation call"). The EWS were calculated and updated with every new patient variable entry over time. Scores were considered accurate if they predicted an outcome in the following 24 hours. RESULTS All EWS demonstrated higher performance within the medical population as compared to surgical: higher positive predictive value (P < .0001 for all scores) and sensitivity (P < .0001 for all scores). All EWS had positive predictive values below 25%. CONCLUSIONS The overall poor performance of the evaluated EWS was marginally better in medical patients when compared to surgical patients. Journal of Hospital Medicine 2017;12:217-223.
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Affiliation(s)
- Anil N. Makam
- Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, University of Texas Southwestern Medical Center, Dallas, Texas
- Address for correspondence and reprint requests: Anil N. Makam, MD, MAS, 5323 Harry Hines Blvd., Dallas, TX 75390-9169; Telephone: 214-648-3272; Fax: 214-648-3232;
| | - Oanh K. Nguyen
- Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher Clark
- Office of Research Administration, Parkland Health and Hospital System, Dallas, Texas
| | - Ethan A. Halm
- Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Division of Outcomes and Health Services Research, University of Texas Southwestern Medical Center, Dallas, Texas
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Lee YJ, Lee DS, Min H, Choi YY, Lee EY, Song I, Yoon YE, Kim JW, Park JS, Cho YJ, Lee JH, Suh JW, Jo YH, Kim K, Park S. Differences in the Clinical Characteristics of Rapid Response System Activation in Patients Admitted to Medical or Surgical Services. J Korean Med Sci 2017; 32:688-694. [PMID: 28244298 PMCID: PMC5334170 DOI: 10.3346/jkms.2017.32.4.688] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 12/28/2016] [Indexed: 11/20/2022] Open
Abstract
Variability in rapid response system (RRS) characteristics based on the admitted wards is unknown. We aimed to compare differences in the clinical characteristics of RRS activation between patients admitted to medical versus surgical services. We reviewed patients admitted to the hospital who were detected by the RRS from October 2012 to February 2014 at a tertiary care academic hospital. We compared the triggers for RRS activation, interventions performed, and outcomes of the 2 patient groups. The RRS was activated for 460 patients, and the activation rate was almost 2.3 times higher for surgical services than that for medical services (70% vs. 30%). The triggers for RRS activation significantly differed between patient groups (P = 0.001). They included abnormal values for the respiratory rate (23.2%) and blood gas analysis (20.3%), and low blood pressure (18.8%) in the medical group; and low blood pressure (32.0%), low oxygen saturation (20.8%), and an abnormal heart rate (17.7%) in the surgical group. Patients were more likely classified as do not resuscitate or required intensive care unit admission in the medical group compared to those in the surgical group (65.3% vs. 54.7%, P = 0.045). In multivariate analysis, whether the patient belongs to medical services was found to be an independent predictor of mortality after adjusting for the modified early warning score, Charlson comorbidity index, and intervention performed by the RRS team. Our data suggest that RRS triggers, interventions, and outcomes greatly differ between patient groups. Further research is needed to evaluate the efficacy of an RRS approach tailored to specific patient groups.
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Affiliation(s)
- Yeon Joo Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Seon Lee
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyunju Min
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yun Young Choi
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Young Lee
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Inae Song
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anesthesiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yeonyee E Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin Won Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Sun Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Jae Cho
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Won Suh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyuseok Kim
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sangheon Park
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anesthesiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anesthesiology, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, United Arab Emirates.
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Cardiorespiratory instability in monitored step-down unit patients: using cluster analysis to identify patterns of change. J Clin Monit Comput 2017; 32:117-126. [PMID: 28229353 DOI: 10.1007/s10877-017-0001-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/08/2017] [Indexed: 01/07/2023]
Abstract
Cardiorespiratory instability (CRI) in monitored step-down unit (SDU) patients has a variety of etiologies, and likely manifests in patterns of vital signs (VS) changes. We explored use of clustering techniques to identify patterns in the initial CRI epoch (CRI1; first exceedances of VS beyond stability thresholds after SDU admission) of unstable patients, and inter-cluster differences in admission characteristics and outcomes. Continuous noninvasive monitoring of heart rate (HR), respiratory rate (RR), and pulse oximetry (SpO2) were sampled at 1/20 Hz. We identified CRI1 in 165 patients, employed hierarchical and k-means clustering, tested several clustering solutions, used 10-fold cross validation to establish the best solution and assessed inter-cluster differences in admission characteristics and outcomes. Three clusters (C) were derived: C1) normal/high HR and RR, normal SpO2 (n = 30); C2) normal HR and RR, low SpO2 (n = 103); and C3) low/normal HR, low RR and normal SpO2 (n = 32). Clusters were significantly different based on age (p < 0.001; older patients in C2), number of comorbidities (p = 0.008; more C2 patients had ≥ 2) and hospital length of stay (p = 0.006; C1 patients stayed longer). There were no between-cluster differences in SDU length of stay, or mortality. Three different clusters of VS presentations for CRI1 were identified. Clusters varied on age, number of comorbidities and hospital length of stay. Future study is needed to determine if there are common physiologic underpinnings of VS clusters which might inform clinical decision-making when CRI first manifests.
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Abstract
Surveillance and monitoring each represent a distinct process in patient care. Monitoring involves observation, measurement, and recording of physiological parameters, while surveillance is a systematic, goal-directed process based on early detection of signs of change, interpretation of the clinical implications of such changes, and initiation of rapid, appropriate interventions. Through use of an illustrative clinical example based on Early Warning System scoring and rapid response teams, this article seeks to distinguish between nurse monitoring and surveillance to demonstrate the impact of surveillance on improving both care processes and patient care. Using a clinical example, differences between surveillance and monitoring as a trigger for deployment of the rapid response team were reviewed. The use of surveillance versus monitoring resulted in a mean reduction in rapid response team deployment time of 291 minutes. The median hospital length of stay for patients whose clinical care included using surveillance to initiate the deployment of the rapid response team was reduced by 4 days. Monitoring relies on observation and assessment while nursing surveillance incorporates monitoring with recognition and interpretation of the clinical implications of changes to guide decisions about subsequent actions. The clinical example described here supports that the use of an automated surveillance system versus monitoring had a measurable impact on clinical care.
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59
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Bellew SD, Cabrera D, Lohse CM, Bellolio MF. Predicting Early Rapid Response Team Activation in Patients Admitted From the Emergency Department: The PeRRT Score. Acad Emerg Med 2017; 24:216-225. [PMID: 27611487 DOI: 10.1111/acem.13077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/25/2016] [Accepted: 08/28/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Rapid response teams (RRTs) respond to signs of deterioration to avoid morbidity and mortality. Early RRT activation (eRRT) in patients admitted from the emergency department (ED) is associated with significantly increased mortality. Predicting these events may represent an opportunity to identify patients who would benefit from further resuscitation, aid disposition decision-making, or improve communication between ED and inpatient providers. We aimed to create a clinical prediction instrument to quantify the risk of eRRT. METHODS We performed an observational cohort study of patients admitted to a non-intensive care unit (ICU) setting who triggered eRRT from January 2009 to December of 2012 compared to those who did not trigger eRRT. Age, sex, ED vital sign measurements, and final ED diagnosis by ICD-9 code were evaluated in a multivariable logistic regression model. The performance of prediction models was assessed using discrimination summarized by area under a receiver operating curve (AUC) and calibration with the Hosmer and Lemeshow goodness-of-fit test. The final model was used to create a simplified scoring system. RESULTS The eRRT group consisted of 474 patients who were compared to 2,575 patients in the reference group. Age and sex did not add significant discrimination to the model and were eliminated from the simplified, final model. This model, which included vital signs and diagnosis category, was found to have an AUC of 0.754 (95% confidence interval [CI] = 0.730 to 0.778) and was used to create a simplified scoring system. The odds ratio for the association of a 1-unit increase in risk score with eRRT was 1.37 (95% CI = 1.32 to 1.41; p < 0.001). When internally validated, the score was found to have an AUC of 0.759 (95% CI = 0.735 to 0.753). Calculated scores ranged from -3 to 18, which corresponded to predicted probabilities of eRRT ranging from 5.1% to 72.2%. CONCLUSIONS In summary, the PeRRT score is a simple tool that can be referenced by emergency providers at the bedside to quantify the risk of early RRT activation and potential deterioration, helping to answer the question, "How likely is my patient to trigger an RRT activation in the next twelve hours?" Given that patients who trigger eRRT have an elevated risk of morbidity and mortality, higher scores should result in resuscitative intervention, further observation in the ED, consideration of ICU admission, or direct enhanced communication between ED and inpatient providers. A prospective multicenter study is required to further validate this instrument.
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Affiliation(s)
| | - Daniel Cabrera
- Department of Emergency Medicine Mayo Clinic Rochester MN
| | - Christine M. Lohse
- Division of Biomedical Statistics and Informatics Mayo Clinic Rochester MN
| | - M. Fernanda Bellolio
- Department of Emergency Medicine Mayo Clinic Rochester MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
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Waldie J, Tee S, Day T. Reducing avoidable deaths from failure to rescue: a discussion paper. ACTA ACUST UNITED AC 2017; 25:895-900. [PMID: 27615523 DOI: 10.12968/bjon.2016.25.16.895] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM This article proposes a radical new approach to the monitoring and governance of services, and the education and training of nurses to meet 'failure to rescue' requirements. BACKGROUND Healthcare policy in the UK that seeks to ensure safe and effective services for the acutely ill has largely failed, resulting in adult patients dying unnecessarily. Despite grand rhetoric, UK governments have distanced themselves from implementation, resulting in patchy localised developments and creating inconsistent service responses. DESIGN AND DATA SOURCES This article draws on a review of research and UK policy literature and best international practice to propose a new national framework approach that combines competency development, governance and performance monitoring to address 'failure to rescue' shortcomings. IMPLICATIONS FOR NURSING Paramount is a nationally agreed and fit-for-purpose competency tool using simulation to assess staff in order to improve recognition of the deteriorating patient. Service improvements should include increased investment in telemedicine; service performance should be communicated through publicly available ratings and overseen by patient panels; and governance will require strengthening through enhanced Care Quality Commission/Monitor input, which should be linked to the maintenance of foundation trust status. CONCLUSION Health professional bodies, regulators, providers and the Government must work together to strengthen the safety and effectiveness of acute services. This will require investment in staff competency and enhancement of the governance to ensure services consistently meet public expectations and reduce unnecessary deaths.
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Affiliation(s)
- James Waldie
- Critical Care Nurse, Guy's and St Thomas' NHS Foundation Trust, London
| | | | - Tina Day
- Lecturer, Florence Nightingale Faculty of Nursing and Midwifery, King's College London
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White K, Scott IA, Vaux A, Sullivan CM. Rapid response teams in adult hospitals: time for another look? Intern Med J 2016; 45:1211-20. [PMID: 26122775 DOI: 10.1111/imj.12845] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 06/23/2015] [Indexed: 11/28/2022]
Abstract
Rapid response teams (RRT), alternatively termed medical emergency teams, have become part of the clinical landscape in the majority of adult hospitals throughout Australia and New Zealand. These teams aim to bring critical care expertise to the bedside of clinically deteriorating patients residing in general hospital wards with the aim of preventing adverse outcomes, in particular death or cardiorespiratory arrests. While the concept of RRT has considerable face validity, there is little high quality evidence of their effectiveness and much uncertainty as to the optimal methods for identifying patients in need of RRT and calling the RRT (afferent limb) and how, and with whom, the RRT should then respond (efferent limb). Adverse unintended consequences of RRT systems and the opportunity costs involved in maintaining such systems have not been subject to study, amid concerns RRT may be compensating for other potentially remediable system of care failures. This article presents an overview of the current state of play of RRT in hospital practice as they pertain to the care of adult patients and identifies several issues around their implementation and evaluation that should be subject to further research.
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Affiliation(s)
- K White
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - I A Scott
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - A Vaux
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - C M Sullivan
- Division of Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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62
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Salvatierra GG, Bindler RC, Daratha KB. Rapid Response Teams: Is it Time to Reframe the Questions of Rapid Response Team Measurement? J Nurs Scholarsh 2016; 48:616-623. [PMID: 27668841 DOI: 10.1111/jnu.12252] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this article is to present an overview of rapid response team (RRT) history in the United States, provide a review of prior RRT effectiveness research, and propose the reframing of four new questions of RRT measurement that are designed to better understand RRTs in the context of contemporary nursing practice as well as patient outcomes. ORGANIZING CONSTRUCT RRTs were adopted in the United States because of their intuitive appeal, and despite a lack of evidence for their effectiveness. Subsequent studies used mortality and cardiac arrest rates to measure whether or not RRTs "work." Few studies have thoroughly examined the effect of RRTs on nurses and on nursing practice. METHODS An extensive literature review provided the background. Suppositions and four critical, unanswered questions arising from the literature are suggested. FINDINGS The results of RRT effectiveness, which have focused on patient-oriented outcomes, have been ambiguous, contradictory, and difficult to interpret. Additionally, they have not taken into account the multiple ways in which these teams have impacted nurses and nursing practice as well as patient outcomes. CONCLUSIONS What happens in terms of RRT process and utilization is likely to have a major impact on nurses and nursing care on general medical and surgical wards. What that impact will be depends on what we can learn from measuring with an expanded yardstick, in order to answer the question, "Do RRTs work?" CLINICAL RELEVANCE Evidence for the benefits of RRTs depends on proper framing of questions relating to their effectiveness, including the multiple ways RRTs contribute to nursing efficacy.
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Affiliation(s)
- Gail G Salvatierra
- Assistant Professor, School of Nursing, California State University, San Marcos, CA, USA.
| | - Ruth C Bindler
- Professor Emeritus, College of Nursing, Washington State University, Spokane, WA, USA
| | - Kenn B Daratha
- Associate Professor, Washington State University College of Nursing, Spokane, WA, USA.,Affiliate Associate Professor, Washington State University Elson S. Floyd College of Medicine, Spokane, WA, USA
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63
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Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars MB, Smith GB, Sunde K, Deakin CD. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2016; 95:100-47. [PMID: 26477701 DOI: 10.1016/j.resuscitation.2015.07.016] [Citation(s) in RCA: 926] [Impact Index Per Article: 115.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK.
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Germany
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Heart of England NHS Foundation Trust, Birmingham, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
| | - Pierre Carli
- SAMU de Paris, Department of Anaesthesiology and Intensive Care, Necker University Hospital, Paris, France
| | - Tommaso Pellis
- Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Gary B Smith
- Centre of Postgraduate Medical Research & Education, Bournemouth University, Bournemouth, UK
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton, Southampton, UK
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Missed opportunities in use of medical emergency teams prior to in-hospital cardiac arrest. Am Heart J 2016; 177:87-95. [PMID: 27297853 DOI: 10.1016/j.ahj.2016.04.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/22/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hospitals often employ Medical Emergency Teams (METs) to respond to patients with acute physiological decline so as to prevent deaths from in-hospital cardiac arrest (IHCA). We determined the frequency of missed opportunities for MET evaluation, defined as no MET evaluation prior to IHCA despite evidence of severe vital sign abnormalities ≥1 hour preceding cardiac arrest. METHODS Within Get With The Guidelines-Resuscitation, we identified 21,913 patients from 274 hospitals with IHCA on general inpatient or telemetry floors who would be eligible for a MET evaluation prior to IHCA. We determined the proportion of patients with missed opportunities for MET evaluation, defined as no MET evaluation before IHCA despite at least 1 severe vital sign abnormality (pulse >150 or <30, respiratory rate >35 or <8, systolic blood pressure <80, and oxygen saturation <80%) 1, 2, and 4 hours before IHCA. The relationship between a hospital's proportion of missed opportunities for MET evaluation and its risk-standardized rate of survival to discharge for IHCA (derived using hierarchical linear regression models) was then evaluated. RESULTS Overall, few (3,814 [17.4%]) patients with IHCA had a preceding MET evaluation, and the odds of a MET evaluation varied by >80% across hospitals (median, 14.6% [interquartile range, 9.1%-22.2%]; median odds ratio, 1.82). Vital sign data were available for 13,115 (72.5%) of the 18,099 patients without MET evaluation. Of these patients, 5,243 (40.0%), 4,078 (31.1%), and 1,767 (13.4%) had at least 1 severe vital sign abnormality ≥1, 2, and 4 hours before IHCA, respectively. Hospitals with the highest proportion of unevaluated patients despite severe vital sign abnormalities 2 and 4 hours preceding cardiac arrest had the lowest IHCA survival rate (correlation of -0.14 [P = .04] and -0.16 [P = .01], respectively). CONCLUSIONS Although METs are designed to prevent IHCA, many patients with severe vital sign abnormalities prior to IHCA did not have a MET evaluation, and hospitals with higher rates of unevaluated patients had lower IHCA survival. These findings suggest missed opportunities to efficiently use METs in current practice.
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Delayed Rapid Response Team Activation Is Associated With Increased Hospital Mortality, Morbidity, and Length of Stay in a Tertiary Care Institution. Crit Care Med 2016; 44:54-63. [PMID: 26457753 DOI: 10.1097/ccm.0000000000001346] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify whether delays in rapid response team activation contributed to worse patient outcomes (mortality and morbidity). DESIGN Retrospective observational cohort study including all rapid response team activations in 2012. SETTING Tertiary academic medical center. PATIENTS All those 18 years old or older who had a rapid response team call activated. Vital sign data were abstracted from individual patient electronic medical records for the 24 hours before the rapid response team activation took place. Patients were considered to have a delayed rapid response team activation if more than 1 hour passed between the first appearance in the record of an abnormal vital sign meeting rapid response team criteria and the activation of an rapid response team. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 1,725 patients were included in the analysis. Data were compared between those who had a delayed rapid response team activation and those who did not. Fifty seven percent patients met the definition of delayed rapid response team activation. Patients in high-frequency physiologic monitored environments were more likely to experience delay than their floor counterparts. In the no-delay group, the most common reasons for rapid response team activation were tachycardia/bradycardia at 29% (217/748), respiratory distress/low SpO2 at 28% (213/748), and altered level of consciousness at 23% (170/748) compared with respiratory distress/low SpO2 at 43% (423/977), tachycardia/bradycardia at 33% (327/977), and hypotension at 27% (261/977) in the delayed group. The group with no delay had a higher proportion of rapid response team calls between 8:00 and 16:00, whereas those with delay had a higher proportion of calls between midnight and 08:00. The delayed group had higher hospital mortality (15% vs 8%; adjusted odds ratio, 1.6; p = 0.005); 30-day mortality (20% vs 13%; adjusted odds ratio, 1.4; p = 0.02); and hospital length of stay (7 vs 6 d; relative prolongation, 1.10; p = 0.02) compared with the no-delay group. CONCLUSIONS Delays in rapid response team activation occur frequently and are independently associated with worse patient mortality and morbidity outcomes.
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Chmielewska M, Winters BD, Pandian V, Hillel AT. Integration of a difficult airway response team into a hospital emergency response system. Anesthesiol Clin 2016; 33:369-79. [PMID: 25999009 DOI: 10.1016/j.anclin.2015.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hospital-wide emergency response teams have been an area of development for several decades. Highly specialized to address emergent needs, they mimic the cardiac-pulmonary arrest teams established at hospitals nationwide, such as heart attack, brain attack, medical emergency, rapid response, and difficult airway response teams (DART). The DART at Johns Hopkins Hospital is a collaboration of the Anesthesiology and Critical Care Medicine, Otolaryngology-Head and Neck Surgery, General Surgery, and Emergency Medicine departments. This successful model may be used by other hospitals to establish improved and comprehensive care of the difficult airway patient.
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Affiliation(s)
- Monika Chmielewska
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287-0910, USA
| | - Bradford D Winters
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 1800 Orleans Street, Zayed 9127, Baltimore, MD 21287, USA
| | - Vinciya Pandian
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 1800 Orleans Street, Phipps 409, Baltimore, MD 21287, USA
| | - Alexander T Hillel
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins Hospital, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287-0910, USA.
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Considine J, Jones D, Pilcher D, Currey J. Patient physiological status at the emergency department-ward interface and emergency calls for clinical deterioration during early hospital admission. J Adv Nurs 2016; 72:1287-300. [DOI: 10.1111/jan.12922] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Julie Considine
- Deakin University; Geelong Victoria Australia
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research; Burwood Victoria Australia
- Eastern Health - Deakin University Nursing & Midwifery Research Centre; Deakin University; Geelong Victoria Australia
| | - Daryl Jones
- Department of Intensive Care; Austin Health; Heidelberg Victoria Australia
| | - David Pilcher
- Alfred Health; Intensive Care Unit; Prahran Victoria Australia
| | - Judy Currey
- Deakin University; Geelong Victoria Australia
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research; Burwood Victoria Australia
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Soar J, Nolan J, Böttiger B, Perkins G, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars M, Smith G, Sunde K, Deakin C. Erweiterte Reanimationsmaßnahmen für Erwachsene („adult advanced life support“). Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0085-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Mitchell A, Schatz M, Francis H. Designing a critical care nurse-led rapid response team using only available resources: 6 years later. Crit Care Nurse 2015; 34:41-55; quiz 56. [PMID: 24882828 DOI: 10.4037/ccn2014412] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Rapid response teams have been introduced to intervene in the care of patients whose condition deteriorates unexpectedly by bringing clinical experts quickly to the patient's bedside. Evidence supporting the need to overcome failure to deliver optimal care in hospitals is robust; whether rapid response teams demonstrate benefit by improving patient safety and reducing the occurrence of adverse events remains controversial. Despite inconsistent evidence regarding the effectiveness of rapid response teams, concerns regarding care and costly consequences of unaddressed deterioration in patients' condition have prompted many hospitals to implement rapid response teams as a patient safety strategy. A cost-neutral structure for a rapid response team led by a nurse from the intensive care unit was implemented with the goal of reducing cardiopulmonary arrests occurring outside the intensive care unit. The results of 6 years' experience indicate that a sustainable and effective rapid response team response can be put into practice without increasing costs or adding positions and can decrease the percentage of cardiopulmonary arrests occurring outside the intensive care unit.
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Affiliation(s)
- Anne Mitchell
- Anne Mitchell is a clinical nurse specialist in the emergency department and intensive care unit at Banner Baywood Medical Center, Mesa, Arizona.Marilyn Schatz is a clinical manager in the intensive care unit at Banner Baywood Medical Center.Heather Francis is the director of nursing of the intensive care unit, dialysis, at Banner Baywood Medical Center.
| | - Marilyn Schatz
- Anne Mitchell is a clinical nurse specialist in the emergency department and intensive care unit at Banner Baywood Medical Center, Mesa, Arizona.Marilyn Schatz is a clinical manager in the intensive care unit at Banner Baywood Medical Center.Heather Francis is the director of nursing of the intensive care unit, dialysis, at Banner Baywood Medical Center
| | - Heather Francis
- Anne Mitchell is a clinical nurse specialist in the emergency department and intensive care unit at Banner Baywood Medical Center, Mesa, Arizona.Marilyn Schatz is a clinical manager in the intensive care unit at Banner Baywood Medical Center.Heather Francis is the director of nursing of the intensive care unit, dialysis, at Banner Baywood Medical Center
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Kronick SL, Kurz MC, Lin S, Edelson DP, Berg RA, Billi JE, Cabanas JG, Cone DC, Diercks DB, Foster J(J, Meeks RA, Travers AH, Welsford M. Part 4: Systems of Care and Continuous Quality Improvement. Circulation 2015; 132:S397-413. [DOI: 10.1161/cir.0000000000000258] [Citation(s) in RCA: 191] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Capan M, Ivy JS, Wilson JR, Huddleston JM. A stochastic model of acute-care decisions based on patient and provider heterogeneity. Health Care Manag Sci 2015; 20:187-206. [PMID: 26490831 PMCID: PMC5415592 DOI: 10.1007/s10729-015-9347-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 10/06/2015] [Indexed: 12/02/2022]
Abstract
The primary cause of preventable death in many hospitals is the failure to recognize and/or rescue patients from acute physiologic deterioration (APD). APD affects all hospitalized patients, potentially causing cardiac arrest and death. Identifying APD is difficult, and response timing is critical - delays in response represent a significant and modifiable patient safety issue. Hospitals have instituted rapid response systems or teams (RRT) to provide timely critical care for APD, with thresholds that trigger the involvement of critical care expertise. The National Early Warning Score (NEWS) was developed to define these thresholds. However, current triggers are inconsistent and ignore patient-specific factors. Further, acute care is delivered by providers with different clinical experience, resulting in quality-of-care variation. This article documents a semi-Markov decision process model of APD that incorporates patient and provider heterogeneity. The model allows for stochastically changing health states, while determining patient subpopulation-specific RRT-activation thresholds. The objective function minimizes the total time associated with patient deterioration and stabilization; and the relative values of nursing and RRT times can be modified. A case study from January 2011 to December 2012 identified six subpopulations. RRT activation was optimal for patients in “slightly concerning” health states (NEWS > 0) for all subpopulations, except surgical patients with low risk of deterioration for whom RRT was activated in “concerning” states (NEWS > 4). Clustering methods identified provider clusters considering RRT-activation preferences and estimation of stabilization-related resource needs. Providers with conservative resource estimates preferred waiting over activating RRT. This study provides simple practical rules for personalized acute care delivery.
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Affiliation(s)
- Muge Capan
- Value Institute, Christiana Care Health System, John H. Ammon Medical Education Center, 4755 Ogletown-Stanton Road, Newark, DE 19718 USA
| | - Julie S. Ivy
- Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, Campus Box 7906, Raleigh, NC 27695-7906 USA
| | - James R. Wilson
- Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, Campus Box 7906, Raleigh, NC 27695-7906 USA
| | - Jeanne M. Huddleston
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
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The effect of a staged, emergency department specific rapid response system on reporting of clinical deterioration. ACTA ACUST UNITED AC 2015; 18:218-26. [PMID: 26300415 DOI: 10.1016/j.aenj.2015.07.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 07/20/2015] [Accepted: 07/20/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Despite emerging evidence regarding clinical deterioration in emergency department (ED) patients, the widespread uptake of rapid response systems (RRS) in EDs has been limited. AIMS To evaluate the effect of an ED RRS on reporting of clinical deterioration and determine if there were differences between patients who did, and did not, deteriorate during ED care. METHODS A retrospective cross sectional design was used to conduct this single site study in Melbourne, Australia. Stratified random sampling identified 50 patients with shortness of breath, chest pain or abdominal pain per each year studied (2009-2012) giving a total of 600 patients. The intervention was an ED RRS implemented in stages. RESULTS The frequency of clinical deterioration was 14.8% (318 episodes/89 patients). Unreported deterioration decreased each year (86.7%; 68.8%; 55.3%; 54.0%, p=0.141). Patients who deteriorated during ED care had a longer median ED length of stay (2.8h; p<0.001), were 31.9% more likely to need hospital admission (p<0.001) and 4.9% more likely to die in hospital (p=0.044). CONCLUSIONS A staged ED specific RRS decreased the frequency of unreported clinical deterioration. Controlled multi-site studies of ED specific RRSs are needed to examine the effect of formal ED RRSs on patient outcomes.
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Individualizing and optimizing the use of early warning scores in acute medical care for deteriorating hospitalized patients. Resuscitation 2015; 93:107-12. [DOI: 10.1016/j.resuscitation.2014.12.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 11/24/2014] [Accepted: 12/11/2014] [Indexed: 11/18/2022]
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Burke PA, Vest MT, Kher H, Deutsch J, Daya S. Improving Resident Performance Through a Simulated Rapid Response Team: A Pilot Study. J Osteopath Med 2015; 115:444-50. [PMID: 26111132 DOI: 10.7556/jaoa.2015.090] [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 The Joint Commission requires hospitals to develop systems in which a team of clinicians can rapidly recognize and respond to changes in a patient's condition. The rapid response team (RRT) concept has been widely adopted as the solution to this mandate. The role of house staff in RRTs and the impact on resident education has been controversial. At Christiana Care Health System, eligible residents in their second through final years lead the RRTs. OBJECTIVE To evaluate the use of a team-based, interdisciplinary RRT training program for educating and training first-year residents in an effort to improve global RRT performance before residents start their second year. METHODS This pilot study was administered in 3 phases. Phase 1 provided residents with classroom-based didactic sessions using case-based RRT scenarios. Multiple choice examinations were administered, as well as a confidence survey based on a Likert scale before and after phase 1 of the program. Phase 2 involved experiential training in which residents engaged as mentored participants in actual RRT calls. A qualitative survey was used to measure perceived program effectiveness after phase 2. In phase 3, led by senior residents, simulated RRTs using medical mannequins were conducted. Participants were divided into 5 teams, in which each resident would rotate in the roles of leader, nurse, and respiratory therapist. This phase measured resident performance with regard to medical decision making, data gathering, and team behaviors during the simulated RRT scenarios. Performance was scored by an attending and a senior resident. RESULTS A total of 18 residents were eligible (N=18) for participation. The average multiple choice test score improved by 20% after didactic training. The average confidence survey score before training was 3.44 out of 5 (69%) and after training was 4.13 (83%), indicating a 14% improvement. High-quality team behaviors correlated with medical decision making (0.92) more closely than did high-quality data gathering (0.11). This difference narrowed during high-pressure scenarios (0.84 and 0.72, respectively). CONCLUSION Our data suggest that resident training using a team-based, interdisciplinary RRT training program may improve resident education, interdisciplinary team-based dynamics, and global RRT performance. In turn, data gathering and medical decision making may be enhanced, which may result in better patient outcomes during RRT scenarios.
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Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care 2015; 19:254. [PMID: 26070457 PMCID: PMC4489005 DOI: 10.1186/s13054-015-0973-y] [Citation(s) in RCA: 341] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/04/2015] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Although rapid response system teams have been widely adopted by many health systems, their effectiveness in reducing hospital mortality is uncertain. We conducted a meta-analysis to examine the impact of rapid response teams on hospital mortality and cardiopulmonary arrest. METHOD We conducted a systematic review of studies published from January 1, 1990, through 31 December 2013, using PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library. We included studies that reported data on the primary outcomes of ICU and in-hospital mortality or cardiopulmonary arrests. RESULTS Twenty-nine eligible studies were identified. The studies were analysed in groups based on adult and paediatric trials that were further sub-grouped on methodological design. There were 5 studies that were considered either cluster randomized control trial, controlled before after or interrupted time series. The remaining studies were before and after studies without a contemporaneous control. The implementation of RRS has been associated with an overall reduction in hospital mortality in both the adult (RR 0.87, 95 % CI 0.81-0.95, p<0.001) and paediatric (RR=0.82 95 % CI 0.76-0.89) in-patient population. There was substantial heterogeneity in both populations. The rapid response system team was also associated with a reduction in cardiopulmonary arrests in adults (RR 0.65, 95 % CI 0.61-0.70, p<0.001) and paediatric (RR=0.64 95 % CI 0.55-0.74) patients. CONCLUSION Rapid response systems were associated with a reduction in hospital mortality and cardiopulmonary arrest. Meta-regression did not identify the presence of a physician in the rapid response system to be significantly associated with a mortality reduction.
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Affiliation(s)
- Ritesh Maharaj
- Kings College London, Denmark Hill, London, SE5 9RW, UK.
- Department of Critical Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RW, UK.
- Department of Critical Care Medicine, Kings College London, Ground Floor, Cheyne Wing, Denmark Hill, London, SE5 9RS, UK.
| | - Ivan Raffaele
- Department of Critical Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RW, UK.
| | - Julia Wendon
- Kings College London, Denmark Hill, London, SE5 9RW, UK.
- Department of Critical Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RW, UK.
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Evaluating processes of care and outcomes of children in hospital (EPOCH): study protocol for a randomized controlled trial. Trials 2015; 16:245. [PMID: 26033094 PMCID: PMC4458338 DOI: 10.1186/s13063-015-0712-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 04/08/2015] [Indexed: 11/15/2022] Open
Abstract
Background The prevention of near and actual cardiopulmonary arrest in hospitalized children is a patient safety imperative. Prevention is contingent upon the timely identification, referral and treatment of children who are deteriorating clinically. We designed and validated a documentation-based system of care to permit identification and referral as well as facilitate provision of timely treatment. We called it the Bedside Paediatric Early Warning System (BedsidePEWS). Here we describe the rationale for the design, intervention and outcomes of the study entitled Evaluating Processes and Outcomes of Children in Hospital (EPOCH). Methods/Design EPOCH is a cluster-randomized trial of the BedsidePEWS. The unit of randomization is the participating hospital. Eligible hospitals have a Pediatric Intensive Care Unit (PICU), are anticipated to have organizational stability throughout the study, are not using a severity of illness score in hospital wards and are willing to be randomized. Patients are >37 weeks gestational age and <18 years and are hospitalized in inpatient ward areas during all or part of their hospital admission. Randomization is to either BedsidePEWS or control (no severity of illness score) in a 1:1 ratio within two strata (<200, ≥200 hospital beds). All-cause hospital mortality is the selected primary outcome. It is objective, independent of do-not-resuscitate status and can be reliably measured. The secondary outcomes include (1) clinical outcomes: clinical deterioration, severity of illness at and during ICU admission, and potentially preventable cardiac arrest; (2) processes of care outcomes: immediate calls for assistance, hospital and ICU readmission, and perceptions of healthcare professionals; and (3) resource utilization: ICU days and use of ICU therapies. Discussion Following funding by the Canadian Institutes of Health Research and local ethical approvals, site enrollment started in 2010 and was closed in February 2014. Patient enrollment is anticipated to be complete in July 2015. The results of EPOCH will strengthen the scientific basis for local, regional, provincial and national decision-making and for the recommendations of national and international bodies. If negative, the costs of hospital-wide implementation can be avoided. If positive, EPOCH will have provided a scientific justification for the major system-level changes required for implementation. Trial registration: NCT01260831 ClinicalTrials.gov date: 14 December 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0712-3) contains supplementary material, which is available to authorized users.
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Ha SW, Choi YJ, Lee SE, Chi SI, Kim HJ, Han JH, Han HJ, Lee EH, Kim HJ, Seo KS. Emergency response team activation in the outpatient clinic of a single dental teaching hospital in Korea: a retrospective study of 10 years' records. J Dent Anesth Pain Med 2015; 15:77-83. [PMID: 28879262 PMCID: PMC5564102 DOI: 10.17245/jdapm.2015.15.2.77] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 06/24/2015] [Accepted: 06/25/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To prepare for possible emergency situations during dental treatment, it is helpful to know how often and what kinds of emergencies may arise. This study set out to evaluate the incidences, causes, treatments, and outcomes of emergency situations in the outpatient clinic of a dental teaching hospital in Korea. METHODS We retrospectively reviewed the records of patients who had experienced an emergency situation and emergency response team activated in a selected outpatient clinic between November 2004 and November 2013. Specific information about the emergency cases was collected, including the patient characteristics and the frequency, types, treatments, and outcomes of the emergency situations. RESULTS We identified 35 instances of emergency situations in 2,890,424 patients (incidence = 0.012 per 10,000 outpatients). The number of cases was as follows: 10 (28.6%) in the Department of Periodontics, 10 (28.6%) in the Department of Oral and Maxillofacial Surgery, 6 (17.1%) in the Department of Oral and Maxillofacial Radiology, 4 (11.4%) in the Department of Prosthodontics, 2 (5.7%) in the Department of Conservative Dentistry, 2 (5.7%) in the Department of Pediatric Dentistry, and 1 (2.9%) in the Department of Orthodontics. Three (8.6%) of the emergency situations arose before treatment, 22 (62.9%) during treatment, 7 (20.0%) after treatment, and 2 (5.7%) in a patient's guardian. CONCLUSIONS In accordance with the growing elderly population and more aggressive dental procedures, the number of emergency situations may increase in the future. We recommend that clinicians keep in mind airway management and the active control of emergency situations.
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Affiliation(s)
- Sang Woon Ha
- School of Dentistry, Seoul National University, Seoul, Korea
| | - Yoon Ji Choi
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Soo Eon Lee
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Seong In Chi
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Hye-Jung Kim
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Jin-Hee Han
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Hee-Jeong Han
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Eun-Hee Lee
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
| | - Hyun Jeong Kim
- Department of Dental Anesthesiology, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea
| | - Kwang-Suk Seo
- Department of Dental Anesthesiology, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea
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Reza N, Dudzinski DM. Pulmonary embolism response teams. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:387. [PMID: 25947348 DOI: 10.1007/s11936-015-0387-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OPINION STATEMENT Pulmonary embolism (PE) is a complex and multidimensional pathophysiology, the diagnosis and management of which spans multiple disciplines. The high morbidity and associated mortality of "massive" and "submassive" acute PE may require prompt, definitive management; however, current consensus guidelines in this domain are not supported by high-level evidence. Randomized clinical trials comparing available pharmacologic and invasive treatment modalities-including anticoagulation, thrombolysis, and embolectomy-have not been conducted and continue to be challenging to conceptualize, design, and execute. Consequently, time-sensitive therapeutic determinations are largely not standardized, and rendered on a case-by-case basis in part depending on institutional practices and expertises. Chronic sequelae of PE, such as chronic thromboembolic pulmonary hypertension and right heart failure, are increasingly identified as conditions necessitating longitudinal specialty care. These and other challenges have created a niche for a multidisciplinary team which can respond rapidly to unstable patient scenarios, appropriately deploy resources, and offer highly specialized acute and chronic management of PE. The Massachusetts General Hospital Pulmonary Embolism Response Team (PERT), modeled after existing rapid response and collaborative care teams, is a novel approach that combines this clinical service with the development of an educational and research framework to advance the care of patients with PE.
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Affiliation(s)
- Nosheen Reza
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Gray 7-730, Boston, MA, 02114, USA,
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Al-Rajhi A, Mardini L, Jayaraman D. The Impact of Implementation of an ICU Consult Service on Hospital-Wide Outcomes and ICU-Specific Outcomes. J Intensive Care Med 2015; 31:478-84. [PMID: 25922386 DOI: 10.1177/0885066615583794] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 03/18/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Rapid response teams (RRTs) were developed to promote assessment of and early intervention for clinically deteriorating hospitalized patients. Although the ideal composition of RRTs is not known, their implementation does require significant resources. OBJECTIVE To test the effectiveness of a dedicated daytime/weekday intensive care unit (ICU) consult service without formal training of ward teams. METHODS Pre- and postintervention study with weekends/nights during implementation period acting as a concurrent control. SETTING An adult tertiary care university center in Montreal without an RRT. INTERVENTION A daytime/weekday ICU consult service with a dedicated intensivist. RESULTS Total hospital mortality rate did not differ between the control and the implementation period (6.65% vs 6.60%; P = .84). The hospital code blue rates also did not differ (1.21/1000 vs 1.14/1000 patient days; P = .58). In contrast, 30-day mortality of patients admitted to the ICU following an ICU consult decreased (39% vs 24% P = .01). Multivariate analysis confirmed this effect on 30-day mortality (odds ratio for implementation period: 0.53 [95% confidence interval: 0.33-0.85] P = .009). The 14-day ICU readmission rate was reduced with the intervention (5.1% vs 4.1%; P < .001). The effect on 30-day mortality and ICU readmissions were only present during daytime/weekdays. CONCLUSION Implementation of an ICU consult service without any formal afferent limb training was associated with decreased mortality and 14-day readmission rates of patients admitted to the ICU. In contrast, hospital-wide mortality and code blue rates were unaffected.
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Affiliation(s)
- Amjad Al-Rajhi
- Critical Care Medicine Department, McGill University, Montreal, Quebec, Canada
| | - Louay Mardini
- Critical Care Medicine Department, McGill University, Montreal, Quebec, Canada
| | - Dev Jayaraman
- McGill University Health Centre and SMDB Jewish General Hospital, Montreal, Quebec, Canada
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82
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Education for cardiac arrest--Treatment or prevention? Resuscitation 2015; 92:59-62. [PMID: 25921543 DOI: 10.1016/j.resuscitation.2015.04.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/01/2015] [Accepted: 04/17/2015] [Indexed: 11/23/2022]
Abstract
In-hospital cardiac arrests (IHCA) occur infrequently and individual staff members working on general wards may only rarely encounter one. Mortality following IHCA is high and the evidence for the benefits of many advanced life support (ALS) interventions is scarce. Nevertheless, regular, often frequent, ALS training is mandatory for many hospital medical staff and nurses. The incidence of pre-cardiac arrest deterioration is much higher than that of cardiac arrests, and there is evidence that intervention prior to cardiac arrest can reduce the incidence of IHCA. This article discusses a proposal to reduce the emphasis on widespread ALS training and to increase education in the recognition and response to pre-arrest clinical deterioration.
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83
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Davis DP, Graham PG, Husa RD, Lawrence B, Minokadeh A, Altieri K, Sell RE. A performance improvement-based resuscitation programme reduces arrest incidence and increases survival from in-hospital cardiac arrest. Resuscitation 2015; 92:63-9. [PMID: 25906942 DOI: 10.1016/j.resuscitation.2015.04.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 04/06/2015] [Accepted: 04/15/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Traditional resuscitation training models are inadequate to achieving and maintaining resuscitation competency. This analysis evaluates the effectiveness of a novel, performance improvement-based inpatient resuscitation programme. METHODS This was a prospective, before-and-after study conducted in an urban, university-affiliated hospital system. All inpatient adult cardiac arrest victims without an active Do Not Attempt Resuscitation order from July 2005 to June 2012 were included. The advanced resuscitation training (ART) programme was implemented in Spring 2007 and included a unique treatment algorithm constructed around the capabilities of our providers and resuscitation equipment, a training programme with flexible format and content including early recognition concepts, and a comprehensive approach to performance improvement feeding directly back into training. Our inpatient resuscitation registry and electronic patient care record were used to quantify arrest rates and survival-to-hospital discharge before and after ART programme implementation. Multiple logistic regression analysis was used to adjust for age, gender, location of arrest, initial rhythm, and time of day. RESULTS A total of 556 cardiac arrest victims were included (182 pre- and 374 post-ART). Arrest incidence decreased from 2.7 to 1.2 per 1000 patient discharges in non-ICU inpatient units, with no change in ICU arrest rate. An increase in survival-to-hospital discharge from 21 to 45% (p < 0.01) was observed following ART programme implementation. Adjusted odds ratios for survival-to-discharge (OR 2.2, 95% CI 1.4-3.4) and good neurological outcomes (OR 3.0, 95% CI 1.7-5.3) reflected similar improvements. Arrest-related deaths decreased from 2.1 to 0.5 deaths per 1000 patient discharges in non-ICU areas and from 1.5 to 1.3 deaths per 1000 patient discharges in ICU areas, and overall hospital mortality decreased from 2.2% to 1.8%. CONCLUSIONS Implementation of a novel, performance improvement-based inpatient resuscitation programme was associated with a decrease in the incidence of cardiac arrest and improved clinical outcomes.
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Affiliation(s)
- Daniel P Davis
- Department of Emergency Medicine, University of California at San Diego, United States.
| | - Patricia G Graham
- Department of Nursing Education, Development, Research, University of California at San Diego, United States
| | - Ruchika D Husa
- Division of Cardiology, University of California at San Diego, United States; Division of Cardiology, Ohio State University, United States
| | - Brenna Lawrence
- Department of Nursing, University of California at San Diego, United States
| | - Anushirvan Minokadeh
- Department of Anesthesiology, University of California at San Diego, United States
| | - Katherine Altieri
- School of Medicine, University of California at San Diego, United States
| | - Rebecca E Sell
- Division of Pulmonary and Critical Care Medicine, University of California at San Diego, United States
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84
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Smith RJ, Santamaria JD, Faraone EE, Holmes JA, Reid DA, Tobin AE. The duration of hospitalization before review by the rapid response team: A retrospective cohort study. J Crit Care 2015; 30:692-7. [PMID: 25981444 DOI: 10.1016/j.jcrc.2015.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 04/01/2015] [Accepted: 04/04/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study is to compare cases of rapid response team (RRT) review for early deterioration (<48 hours after admission), intermediate deterioration (48 to <168 hours after admission), late deterioration (≥168 hours after admission), and cardiac arrest and to determine the association between duration of hospitalization before RRT review and mortality. METHODS This is a retrospective cohort study of RRT cases from a single hospital over 5 years (2009-2013) using administrative data and data for the first RRT attendance of each hospital episode. RESULTS Of 2843 RRT cases, 971 (34.2%) were early deterioration, 917 (32.3%) intermediate, 775 (27.3%) late, and 180 (6.3%) cardiac arrest. Compared with early deterioration patients, late deterioration patients were older (median, 71 vs 69 years; P = .005), had a higher Charlson comorbidity index (median, 2 vs 1; P < .001), more often had RRT review for respiratory distress (32.5% vs 23.5%; P < .001), more often received RRT-initiated not for resuscitation orders (8.4% vs 3.9%; P < .001), less often were discharged directly home (27.9% vs 58.4%; P < .001), and more often died in hospital (30.6% vs 12.8%; P < .001). Compared with early deterioration and adjusted for confounders, the odds ratio of death in hospital for late deterioration was 2.36 (1.81-3.08; P < .001). CONCLUSIONS Late deterioration is frequently encountered by the RRT and, compared with early deterioration, is associated with greater clinical complexity and a worse hospital outcome.
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Affiliation(s)
- Roger J Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - Espedito E Faraone
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - Jennifer A Holmes
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - David A Reid
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - Antony E Tobin
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
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85
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Kapu AN, Wheeler AP, Lee B. Addition of acute care nurse practitioners to medical and surgical rapid response teams: a pilot project. Crit Care Nurse 2015; 34:51-9. [PMID: 24488890 DOI: 10.4037/ccn2014847] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Background Vanderbilt University Hospital's original rapid response team included a critical care charge nurse and a respiratory therapist. A frequently identified barrier to care was the time delay between arrival of the rapid response team and arrival of the primary health care team. Objective To assess the impact of adding an acute care nurse practitioner to the rapid response team. Methods Acute care nurse practitioners were added to surgical and medical rapid response teams in January 2011 to diagnose and order treatments on rapid response calls. Results In 2011, the new teams responded to 898 calls, averaging 31.8 minutes per call. The most frequent diagnoses were respiratory distress (18%), postoperative pain (13%), hypotension (12%), and tachyarrhythmia (10%). The teams facilitated 360 transfers to intensive care and provided 3056 diagnostic and therapeutic interventions. Communication with the primary team was documented on 97% of the calls. Opportunities for process improvement were identified on 18% of the calls. After implementation, charge nurses were surveyed, with 96% expressing high satisfaction associated with enhanced service and quality. Conclusions Teams led by nurse practitioners provide diagnostic expertise and treatment, facilitation of transfers, team communication, and education.
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86
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Kawaguchi R, Nakada TA, Oshima T, Abe R, Matsumura Y, Oda S. Reduction of unexpected serious adverse events after introducing medical emergency team. Acute Med Surg 2015; 2:244-249. [PMID: 29123731 DOI: 10.1002/ams2.101] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 10/23/2014] [Indexed: 11/09/2022] Open
Abstract
Aim To assess the clinical benefits of introducing a medical emergency team system for early medical intervention in hospital care. Methods This prospective analysis included all cases of medical emergency team activation during the first year after the introduction of the medical emergency team system at Chiba University Hospital (Chiba, Japan) in February 2011. The rates of in-hospital mortality and unexpected events before and after introduction of the medical emergency team system were compared. Results The total number of medical emergency team activation calls was 83 (4.9 per 1,000 admissions). The activation of the medical emergency team system was requested most frequently from the general ward (56.6%) and by a physician (57.8%), with the most important reasons for activation being cardiac arrest (37.3%), breathing abnormality (33.7%), and impaired consciousness (32.5%). The most frequent medical interventions by the medical emergency team were intubation (43.3%) and oxygen inhalation (41.0%). Approximately one-half of the patients requiring activation of the medical emergency team system were critically ill and needed subsequent intensive care unit admission. Although no significant difference was observed between the pre- and post- medical emergency team in-hospital mortalities (2.1% versus 2.0%, respectively), the incidence rate of serious events significantly decreased (12.4% versus 6.8%, respectively; P = 0.015). Conclusion Most patients requiring activation of the medical emergency team system were critically ill and needed emergency treatment at the location of the medical emergency team activation, with subsequent critical care. Although the introduction of the medical emergency team system did not affect the in-hospital mortality rate, it reduced the incidence of unexpected serious adverse events, suggesting that it may be clinically useful.
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Affiliation(s)
- Rui Kawaguchi
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Taku Oshima
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Ryuzo Abe
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Yosuke Matsumura
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine Chiba Japan
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87
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Sandroni C, D'Arrigo S, Antonelli M. Rapid response systems: are they really effective? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:104. [PMID: 25887250 PMCID: PMC4361209 DOI: 10.1186/s13054-015-0807-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2015 and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/annualupdate2015. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University of the Sacred Heart, A. Gemelli University Hospital, Rome, Italy.
| | - Sonia D'Arrigo
- Department of Anaesthesiology and Intensive Care, Catholic University of the Sacred Heart, A. Gemelli University Hospital, Rome, Italy.
| | - Massimo Antonelli
- Department of Anaesthesiology and Intensive Care, Catholic University of the Sacred Heart, A. Gemelli University Hospital, Rome, Italy.
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88
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The Cauldron: Desert Island ICU: (Organised by the Trainee Committee). J Intensive Care Soc 2015; 16:8-15. [PMID: 28979362 PMCID: PMC5606493 DOI: 10.1177/1751143715577562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2023] Open
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89
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Talbot MS. Embedding High-Fidelity Simulation Into a Foundations of Nursing Course. Creat Nurs 2015; 21:110-4. [DOI: 10.1891/1078-4535.21.2.110] [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
Delay in recognizing the need for and initiating lifesaving measures is unacceptable in health care. It is never too early to teach novice nursing students to recognize and respond to early warning signs of patient deterioration. The rapid response system was developed to expedite recognition of and response to changes in a patient’s condition. Use of high-fidelity simulation by beginning nursing students to practice recognizing and responding to patient deterioration is vital to both the welfare of patients and the edification of students. Recognizing and responding quickly to patients’ early warning signs of deterioration can determine a patient’s outcome. This article discusses the importance of instructing beginning nursing students in identifying and reacting appropriately to early signs of patient deterioration and in following the chain of command to activate the rapid response team.
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90
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Kitto S, Marshall SD, McMillan SE, Shearer B, Buist M, Grant R, Finnigan M, Wilson S. Rapid response systems and collective (in)competence: An exploratory analysis of intraprofessional and interprofessional activation factors. J Interprof Care 2014; 29:340-6. [DOI: 10.3109/13561820.2014.984021] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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91
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Buist M, Mahoney A. In search of the “Holy Grail”: Will we ever prove the efficacy of Rapid Response Systems (RRS)? Resuscitation 2014; 85:1129-30. [DOI: 10.1016/j.resuscitation.2014.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 07/10/2014] [Indexed: 11/26/2022]
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93
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Affiliation(s)
- W Joshua Frazier
- Nationwide Children's Hospital, Columbus, Ohio; Division of Pediatric Critical Care Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Richard J Brilli
- Nationwide Children's Hospital, Columbus, Ohio; Division of Pediatric Critical Care Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
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95
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Wehbe-Janek H, Pliego J, Sheather S, Villamaria F. System-based interprofessional simulation-based training program increases awareness and use of rapid response teams. Jt Comm J Qual Patient Saf 2014; 40:279-87. [PMID: 25016676 DOI: 10.1016/s1553-7250(14)40037-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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96
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Abstract
Analyses of hospital deaths have indicated that a significant proportion of the reported deaths might have been prevented had the patients received intensive level care early enough. Over the past few decades the critical care response team has become an important means of preventing these deaths. As the proactive arm of intensive care delivery, the critical care response team places emphasis on early identification of signs of clinical deterioration, which then prompts the mobilization of intensive care brought right to the patient's bedside. However, the setting up of a critical care response team is a difficult undertaking involving different levels of cooperation between all service stakeholders, and a bringing together of professional expertise and experience in its operations. The implementation of a critical care response team often involves a high-level restructuring of a hospital's service orientation. In the present work, the various factors and different models to be considered in implementing a critical care response team are addressed.
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Affiliation(s)
- Abdullah Al Shimemeri
- Department of Intensive Care, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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97
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Odell M. Detection and management of the deteriorating ward patient: an evaluation of nursing practice. J Clin Nurs 2014; 24:173-82. [PMID: 25039312 DOI: 10.1111/jocn.12655] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2014] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To audit ward nursing practice in the adherence to an early warning scoring protocol in the detection and initial management of the deteriorating ward patient and investigate factors that may impact on practice. BACKGROUND Hospital inpatients can experience unexpected physiological deterioration leading to poor outcomes and death. Although deterioration can be signalled in the patients' physiological symptoms, evidence suggests that ward staff can miss, misinterpret or mismanage the signs. Rapid response systems have been implemented to address this problem. The rapid response systems consists of two phases: the afferent phase involves monitoring the patient, recognising deterioration and referring to more expert help and the efferent phase involves expert teams assessing and treating the patient. Research has tended to concentrate on the efferent phase of the process and has so far failed to show a significant impact on patient outcome. METHODS Using cardiac arrest as a surrogate marker for deterioration, patient records were retrospectively reviewed during the 12 hours prior to the cardiac arrest event. Data relating to nursing practice and adherence to the early warning scoring protocol were extracted and analysed. FINDINGS The findings suggest that ward nurses' monitoring of patients' observations has improved compared with earlier research, but errors in early warning scoring and nonadherence to referral protocols are still a problem. A number of potentially influential factors on nursing practice were tested, but only deterioration occurring outside normal weekdays was associated with a reduced quality of nursing adherence to protocol. CONCLUSIONS The implementation of rapid response systems may have been an oversimplified solution to the highly complex problem of undetected patient deterioration. There are a multitude of contributory factors to the problem of noncompliance to early warning scoring protocols, and possible solutions will need to reflect the breadth, depth and complexity of the problem if we are to improve patient experience and outcome. RELEVANCE TO CLINICAL PRACTICE An audit of nursing practice against an early warning scoring protocol based on national recommendations and standards in the recording of and response to physiological deterioration in the ward patient has shown that vital signs recording has improved, but early warning scoring accuracy and referral to more expert help remain suboptimal. By identifying areas of suboptimal practice, strategies for education and training and service development can be better informed. More in-depth evidence on factors that may impact the quality of nursing practice has been identified. Problems with rapid response systems assumptions have been highlighted, which may facilitate the implementation of more realistic solutions for managing the deteriorating ward patient.
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Affiliation(s)
- Mandy Odell
- Royal Berkshire NHS Foundation Trust, Reading, Berks, UK
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Yang TM, Kao Y, Wang CT, Chung MH, Lin HJ, Lin SJ, Guo HR, Su SB, Huang CC, Hsu CC. ACLS training: comparison of physicians and nurses with teamwork-based high-fidelity simulation. Am J Emerg Med 2014; 32:1132-4. [PMID: 24974370 DOI: 10.1016/j.ajem.2014.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 05/19/2014] [Accepted: 05/19/2014] [Indexed: 11/17/2022] Open
Affiliation(s)
- Tzu-Meng Yang
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Yuan Kao
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Chia-Ti Wang
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Min-Hsien Chung
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan; Department of Emergency Medicine, Chi-Mei Medical Center, Liouying, Tainan, Taiwan
| | - Hung-Jung Lin
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan; Department of Emergency Medicine, Taipei Medical University, Taipei, Taiwan; Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Shio-Jean Lin
- Department of Pediatrics, Chi-Mei Medical Center, Tainan, Taiwan
| | - How-Ran Guo
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shih-Bin Su
- Department of Occupational Medicine, Chi-Mei Medical Center, Tainan, Taiwan; Department of Leisure, Recreation and Tourism Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan; Department of Medical Research, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Chien-Cheng Huang
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan; Department of Child Care and Education, Southern Taiwan University of Science and Technology, Tainan, Taiwan.
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan; Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan.
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Activation of a medical emergency team using an electronic medical recording-based screening system*. Crit Care Med 2014; 42:801-8. [PMID: 24335439 DOI: 10.1097/ccm.0000000000000031] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the efficacy of a medical emergency team activated using 24-hour monitoring by electronic medical record-based screening criteria followed by immediate intervention by a skilled team. DESIGN Retrospective cohort study. SETTING Academic tertiary care hospital with approximately 2,700 beds. PATIENTS A total of 3,030 events activated by a medical emergency team from March 1, 2008, to February 28, 2010. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS We collected data for all medical emergency team activations: patient characteristics, trigger type for medical emergency team (electronic medical record-based screening vs calling criteria), interventions during each event, outcomes of the medical emergency team intervention, and 28-day mortality after medical emergency team activation. We analyzed data for 2009, when the medical emergency team functioned 24 hours a day, 7 days a week (period 2), compared with that for 2008, when the medical emergency team functioned 12 hours a day, 7 days a week (period 1). The commonest cause of medical emergency team activation was respiratory distress (43.6%), and the medical emergency team performed early goal-directed therapy (21.3%), respiratory care (19.9%), and difficult airway management (12.3%). For patients on general wards, 51.3% (period 1) and 38.4% (period 2) of medical emergency team activations were triggered by the electronic medical record-based screening system (electronic medical record-triggered group). In 23.4%, activation occurred because of an abnormality in laboratory screening criteria. The commonest activation criterion from electronic medical record-based screening was respiratory rate (39.4%). Over half the patients were treated in the general ward, and one third of the patients were transferred to the ICU. The electronic medical record-triggered group had lower ICU admission with an odds ratio of 0.35 (95% CI, 0.22-0.55). In surgical patients, the electronic medical record-triggered group showed the lower 28-day mortality (10.5%) compared with the call-triggered group (26.7%) or the double-triggered group (33.3%) (odds ratio 0.365 with 95% CI, 0.154-0.867, p = 0.022). CONCLUSIONS We successful managed the medical emergency team with electronic medical record-based screening criteria and a skilled intervention team. The electronic medical record-triggered group had lower ICU admission than the call-triggered group or the double-triggered group. In surgical patients, the electronic medical record-triggered group showed better outcome than other groups.
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100
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Effectiveness of a simplified cardiopulmonary resuscitation training program for the non-medical staff of a university hospital. Scand J Trauma Resusc Emerg Med 2014; 22:31. [PMID: 24887037 PMCID: PMC4024185 DOI: 10.1186/1757-7241-22-31] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 05/02/2014] [Indexed: 11/10/2022] Open
Abstract
Background The 2010 Consensus on Science and Treatment Recommendations Statement recommended that short video/computer self-instruction courses, with minimal or no instructor coaching, combined with hands-on practice can be considered an effective alternative to instructor-led basic life support courses. The purpose of this study was to examine the effectiveness of a simplified cardiopulmonary resuscitation (CPR) training program for non-medical staff working at a university hospital. Methods Before and immediately after a 45-min CPR training program consisting of instruction on chest compression and automated external defibrillator (AED) use with a personal training manikin, CPR skills were automatically recorded and evaluated. Participants’ attitudes towards CPR were evaluated by a questionnaire survey. Results From September 2011 through March 2013, 161 participants attended the program. We evaluated chest compression technique in 109 of these participants. The number of chest compressions delivered after the program versus that before was significantly greater (110.8 ± 13.0/min vs 94.2 ± 27.4/min, p < 0.0001), interruption of chest compressions was significantly shorter (0.05 ± 0.34 sec/30 sec vs 0.89 ± 3.52 sec/30 sec, p < 0.05), mean depth of chest compressions was significantly greater (57.6 ± 6.8 mm vs 52.2 ± 9.4 mm, p < 0.0001), and the proportion of incomplete chest compressions of <5 cm among all chest compressions was significantly decreased (8.9 ± 23.2% vs 38.6 ± 42.9%, p < 0.0001). Of the 159 participants who responded to the questionnaire survey after the program, the proportion of participants who answered ‘I can check for a response,’ ‘I can perform chest compressions,’ and ‘I can absolutely or I think I can use an AED’ increased versus that before the program (81.8% vs 19.5%, 77.4% vs 10.1%, 84.3% vs 23.3%, respectively). Conclusions A 45-min simplified CPR training program on chest compression and AED use improved CPR quality and the attitude towards CPR and AED use of non-medical staff of a university hospital.
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