Triggers for emergency team activation: a multicenter assessment

Using rapid response system trigger clusters to characterize patterns of clinical deterioration among hospitalized adult patients

BACKGROUND

Many rapid response system (RRS) events are activated using multiple triggers. However, the patterns in which multiple RRS triggers occur together to activate RRS events are unknown. The purpose of this study was to identify these patterns (RRS trigger clusters) and determine their association with outcomes among hospitalized adult patients.

METHODS

RRS events among adult patients from January 2015 to December 2019 in the Get With The Guidelines- Resuscitation registry's MET module were examined (n = 134,406). Cluster analysis methods were performed to identify RRS trigger clusters. Pearson's chi-squared and ANOVA tests were used to examine differences in patient characteristics across RRS trigger clusters. Multilevel logistic regressions were used to examine the associations between RRS trigger clusters and outcomes.

RESULTS

Six RRS trigger clusters were identified. Predominant RRS triggers for each cluster were: tachypnea, new onset difficulty in breathing, decreased oxygen saturation (Cluster 1); tachypnea, decreased oxygen saturation, staff concern (Cluster 2); respiratory depression, decreased oxygen saturation, mental status changes (Cluster 3); tachycardia, staff concern (Cluster 4); mental status changes (Cluster 5); hypotension, staff concern (Cluster 6). Significant differences in patient characteristics were observed across clusters. Patients in Clusters 3 and 6 had an increased likelihood of in-hospital cardiac arrest (p < 0.01). All clusters had an increased risk of mortality (p < 0.01).

CONCLUSIONS

We discovered six novel RRS trigger clusters with differing relationships to adverse patient outcomes. RRS trigger clusters may prove crucial in clarifying the associations between RRS events and adverse outcomes and aiding in clinician decision-making during RRS events.

The associations between rapid response systems and their components with patient outcomes: A scoping review

Background

While rapid response systems have been widely implemented, their impact on patient outcomes remains unclear. Further understanding of their components-including medical emergency team triggers, medical emergency team member composition, additional roles in patient care beyond responding to medical emergency team events, and their involvement in "Do-Not-Resuscitate" order placement-may elucidate the relationship between rapid response systems and outcomes.

Objective

To explore how recent studies have examined rapid response system components in the context of relevant adverse patient outcomes, such as in-hospital cardiac arrests and hospital mortality.

Design

Scoping review.

Methods

PubMed, CINAHL, and Embase were searched for articles published between November 2014 and June 2022. Studies mainly focused on rapid response systems and associations with in-hospital cardiac arrests were considered. The following were extracted for analysis: study design, location, sample size, participant characteristics, system characteristics (including medical emergency team member composition, additional system roles outside of medical emergency team events), medical emergency team triggers, in-hospital cardiac arrests, and hospital mortality.

Results

Thirty-four studies met inclusion criteria. While most studies described triggers used, few analyzed medical emergency team trigger associations with outcomes. Of those, medical emergency team triggers relating to respiratory abnormalities and use of multiple triggers to activate the medical emergency team were associated with adverse patient outcomes. Many studies described medical emergency team member composition, but the way composition was reported varied across studies. Of the seven studies with dedicated medical emergency team members, six found their systems were associated with decreased incidence of in-hospital cardiac arrests. Six of seven studies that described additional medical emergency team roles in educating staff in rapid response system use found their systems were associated with significant decreases in adverse patient outcomes. Four of five studies that described proactive rounding responsibilities reported found their systems were associated with significant decreases in adverse patient outcomes. Reporting of rapid response system involvement in "Do-Not-Resuscitate" order placement was variable across studies.

Conclusions

Inconsistencies in describing rapid response system components and related data and outcomes highlights how these systems are complex to a degree not fully captured in existing literature. Further large-scale examination of these components across institutions is warranted. Development and use of robust and standardized metrics to track data related to rapid response system components and related outcomes are needed to optimize these systems and improve patient outcomes.

Description and Validation of a Novel Score (Flow Index) as a Clinical Indicator of the Level of Respiratory Support to Children on High Flow Nasal Cannula

This study's objective was to describe and validate flow index (flow rate × FiO 2 /weight) as a method to report the degree of respiratory support by high flow nasal cannula (HFNC) in children. We conducted a retrospective chart review of children managed with HFNC from January 1, 2015 to December 31, 2019. Variables included in the flow index (weight, fraction of inspired oxygen [FiO 2 ], flow rate) and outcomes (hospital and intensive care unit [ICU] length of stay [LOS], escalation to the ICU) were extracted from medical records. Max flow index was defined by the earliest timestamp when patients FiO 2  × flow rate was maximum. Step-wise regression was used to determine the relationship between outcome (LOS and escalation to ICU) and flow index. Fifteen hundred thirty-seven patients met the study criteria. The median first and maximum flow indexes of the population were 24.1 and 38.1. Both first and maximum flow indexes showed a significant correlation with the LOS ( r  = 0.25 and 0.31, p  < 0.001). Correlation for the index was stronger than that of the variables used to calculate them and remained significant after controlling for age, race, sex, and diagnoses. Mild, moderate, and severe categories of first and max flow index were derived using quartiles, and they showed significant age and diagnosis independent association with LOS. Patients with first flow index >20 and maximum flow index >59.5 had increased odds ratio of escalation to ICU (odds ratio: 2.39 and 8.08). The first flow index had a negative association with rapid response activation. Flow index is a valid measure for assessing the degree of respiratory support for children on HFNC.

Rapid Response Systems at a Long-Term Acute Care Hospital

Rapid Response Systems (RRS) improve patient outcomes at large medical centers. Little is known about how RRS are used in other medical settings. The purpose of this exploratory study was to describe RRS events at a long-term acute care hospital (LTACH). We conducted a retrospective review of 71 RRS event records at an urban 50-bed Midwestern LTACH. Measures included demographic data, triggering mechanisms, contextual factors, mechanism factors, and clinical outcomes. Of patients who experienced a RRS event, median age was 71 (62, 80) years; 52.1% were female; most (n = 49, 69%) were "full code." Most (n = 41, 58%) events occurred during the daytime. The most common trigger was "mental status changes/unresponsiveness." Registered nurses were the most frequent activator (n = 19, 26.8%) and responders (n = 63, 60.6%). Median duration of RRS events was 14 (6, 25) minutes. Most patients stabilized and their condition improved (n = 54, 76.1%). RRS can be expanded and modified to the LTACH population.

Using rapid response system trigger clusters to characterize patterns of clinical deterioration among hospitalized adult patients

Background

Many rapid response system (RRS) events are activated using multiple triggers. However, the patterns in which RRS triggers co-occur to activate the medical emergency team (MET) to respond to RRS events is unknown. The purpose of this study was to identify and describe the patterns (RRS trigger clusters) in which RRS triggers co-occur when used to activate the MET and determine the association of these clusters with outcomes using a sample of hospitalized adult patients.

Methods

RRS events among adult patients from January 2015 to December 2019 in the Get With The Guidelines- Resuscitation registry's MET module were examined (n=134,406). A combination of cluster analyses methods was performed to group patients into RRS trigger clusters based on the triggers used to activate their RRS events. Pearson's chi-squared and ANOVA tests were used to examine differences in patient characteristics across RRS trigger clusters. Multilevel logistic regression was used to examine the associations between RRS trigger clusters and outcomes following RRS events.

Results

Six RRS trigger clusters were identified in the study sample. The RRS triggers that predominantly identified each cluster were as follows: tachypnea, new onset difficulty in breathing, and decreased oxygen saturation (Cluster 1); tachypnea, decreased oxygen saturation, and staff concern (Cluster 2); respiratory depression, decreased oxygen saturation, and mental status changes (Cluster 3); tachycardia and staff concern (Cluster 4); mental status changes (Cluster 5); hypotension and staff concern (Cluster 6). Significant differences in patient characteristics were observed across RRS trigger clusters. Patients in Clusters 3 and 6 were associated with an increased likelihood of in-hospital cardiac arrest (IHCA [p<0.01]), while Cluster 4 was associated with a decreased likelihood of IHCA (p<0.01). All clusters were associated with an increased risk of mortality (p<0.01).

Conclusions

We discovered six novel RRS trigger clusters with differing relationships to adverse patient outcomes following RRS events. RRS trigger clusters may prove crucial in clarifying the associations between RRS events and adverse outcomes and may aid in clinician decision-making during RRS events.

Characteristics and outcomes of medical emergency team calls in a Swiss tertiary centre - a retrospective observational study

AIMS OF THE STUDY

To describe reasons for medical emergency team (MET) activation over time, to analyse outcomes, and to describe the circadian distribution of MET calls and Intensive Care Unit (ICU) admissions following MET activation.

METHODS

Monocentric retrospective observational study of prospectively collected data on all MET calls between 1^st of January 2012 until 31^st of May 2019. We analysed data on baselines, referring wards, and disposition of all MET patients. In addition, we allocated all MET calls to the hourly intervals over the 24-hour cycle of the day in order to identify peak times of team activation.

RESULTS

A total of 4068 calls in 3277 patients (37% female, n = 1210) were analysed. The mean age was 65.9 years (± 15.7). The MET dose (defined as MET calls/1000 hospital admissions) remained relatively stable over the years with a median of 8.0 calls/1000 hospitalisations (interquartile range [IQR] 7.0-10.0). A total of 2526 calls (62%) occurred out of hours (17:00 to 8:00). The hourly rate of MET activations was greatest during the evening shift (33.8% of calls in seven hours), followed by the day shift (35.8% calls in nine hours) and night shift (30.4% in eight hours). Over the years, staff concern was the main reason for a MET call (n = 1192, 34%), followed by low peripheral oxygen saturation (SpO₂) not responding to oxygen therapy (n = 776, 22%). Abnormal respiratory rate was a trigger to call the MET in 44 cases (1.3%), and was not documented prior to 2017. Overall, in-hospital mortality was 22%.

CONCLUSION

While most common reasons for MET calls over the years were staff concern and low SpO₂, abnormal respiratory rate was the least frequent, but increased after the introduction of the quick sequential organ failure assessment (qSOFA) in 2016. Most MET calls occurred out of hours with peak hours during the evening shift, highlighting the importance of resource allocation during this shift when planning to introduce a MET system in a hospital. In-hospital mortality after a MET call was 22%.

Clinical Sign-Based Rapid Response Team Call Criteria for Identifying Patients Requiring Intensive Care Management in Japan

Background and Objectives: For effective function of the rapid response system (RRS), prompt identification of patients at a high risk of cardiac arrest and RRS activation without hesitation are important. This study aimed to identify clinical factors that increase the risk of intensive care unit (ICU) transfer and cardiac arrest to identify patients who are likely to develop serious conditions requiring ICU management and appropriate RRS activation in Japan. Materials and Methods: We performed a single-center, case control study among patients requiring a rapid response team (RRT) call from 2017 to 2020. We extracted the demographic data, vital parameters, blood oxygen saturation (SpO₂) and the fraction of inspired oxygen (FiO₂) from the medical records at the time of RRT call. The patients were divided into two groups to identify clinical signs that correlated with the progression of clinical deterioration. Patient characteristics in the two groups were compared using statistical tests based on the distribution. Receiver operating characteristic (ROC) curve analysis was used to identify the appropriate cut-off values of vital parameters or FiO₂ that showed a significant difference between-group. Multivariate logistic regression analysis was used to identify patient factors that were predictive of RRS necessity. Results: We analyzed the data of 65 patients who met our hospital’s RRT call criteria. Among the clinical signs in RRT call criteria, respiratory rate (RR) (p < 0.01) and the needed FiO₂ were significantly increased (p < 0.01) in patients with severe disease course. ROC curve analysis revealed RR and needed FiO₂ cut-off values of 25.5 breaths/min and 30%. The odds ratio for the progression of clinical deterioration was 40.5 times higher with the combination of RR ≥ 26 breaths/min and needed FiO₂ ≥ 30%. Conclusions: The combined use of RR ≥ 26 breaths/min and needed FiO₂ ≥ 30% might be valid for identifying patients requiring intensive care management.

The illness severity of patients reviewed by the medical emergency team: A scoping review

BACKGROUND

Medical emergency teams (METs) are internationally used to manage hospitalised deteriorating patients. Although triggers for MET review and hospital outcomes have previously been widely reported, the illness severity at the point of MET review has not been reported. As such, levels of clinical acuity and patient dependency representing the risk of exposure to short-term adverse clinical outcomes remain largely unknown.

OBJECTIVE

This scoping review sought to understand the illness severity of MET review recipients in terms of acuity and dependency.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The published and grey literature since 2009 was searched to identify relevant articles reporting illness severity scores associated with hospitalised adult inpatients reviewed by a MET. After applying the inclusion and exclusion criteria, 17 articles (16 quantitative studies, one mixed-methods study) were reviewed, summarised, collated, and reported.

RESULTS

A total of 17 studies reported clinical acuity metrics for patients reviewed by a MET. No studies described an integrated risk score encompassing acuity, patient dependency, or wider parameters that might be associated with increased patient risk or the need for intervention. Multi-MET review, the use of specialist interventions, and delayed/transfer to the intensive care unit were associated with a greater risk of clinical deterioration, higher clinical acuity score, and predicted mortality risk. A single dependency metric was not reported although organisational levels of care, the duration of MET review, MET interventions, chronic illness, and frailty were inferred proxy measures.

CONCLUSION

Of the 17 studies reviewed, no single study provided an integrated assessment of illness severity from which to stratify risk or support patient management processes. Patients reviewed by a MET have variable and rapidly changing health needs that make them particularly vulnerable. The lack of high-quality data reporting acuity and dependency limits our understanding of true clinical risk and subsequent opportunities for pathway development.

Assessment of hospital emergency medication kit use at a large academic medical center with automated dispensing machine technology

PURPOSE

Hospital emergency medication kits (HEMKs) are used to provide certain critical medications in emergent situations, despite many technological advancements for patient safety and medication distribution. We sought to evaluate HEMK usage and analyze associated costs to identify and recommend process improvements.

METHODS

Mayo Clinic in Rochester, MN, is a large multisite academic medical center with 2 hospital campuses and many ambulatory clinics. All documentation of the approximately 250 HEMKs in circulation was analyzed from January to November 2017. The primary outcome was HEMK use. Secondary outcomes included individual medication usage and associated costs. These data were then used to recommend process improvements.

RESULTS

Of 880 HEMKs evaluated, 675 (76.7%) were used, resulting in expiration 23.3% of the time. A total of 1,024 emergency medications were used, most commonly for hypoglycemia. Many of these medications are also available in automated dispensing machines for patient care use. Cost analysis revealed an average annual cost of nearly $200,000 associated with HEMKs. The results of our analysis indicated little added benefit of HEMKs in the setting of automated dispensing machine optimization. Steps for HEMK retirement are described.

CONCLUSION

HEMKs offered little added benefit considering technological advancements that have been made in patient safety and medication distribution since their inception. Retirement of HEMKs is anticipated to increase pharmacy operational efficiency by using automated dispensing machine technology and appropriate emergency response protocols to ensure optimal patient care.

Perioperative Medical Emergencies in a 23-Hour Surgical Procedure Unit

Purpose

Our 174-bed hospital operates a 23-hour/day procedure unit without a dedicated on-site high dependency unit or intensive care unit. The purpose of this investigation is to assess the incidence of medical emergency response (MER) and Code Blue (CB) events over 12 months.

Patients and Methods

A retrospective analysis of hospital records was conducted. Patients were identified using the medical emergency team (MET) database. Information pertaining to whether the patient was pre-operative, post-operative (including time and characteristics of the operation), or medical short stay overflow was obtained, in addition to the reason for the MER/CB event and outcome of the event.

Results

Of all hospital events, 8.45% (47 of 550) occurred in the perioperative ward. The incidence rate of events was 0.76% (95% CI: 0.53% to 0.99%) of all scheduled operations. The surgical procedure cancellation rate due to pre-operative MER/CB events was 0.11% (95% CI: 0.02% to 0.20%). Orthopedic surgery and ENT surgery were associated with the highest incidence of MER/CB events. Post-operative hypotension and reduced consciousness associated with vasovagal episodes were the most common clusters. The mean time after the operation for events to occur was 5.21 hours. 25.5% of events occurred outside of standard day surgery operating hours when there was limited access to onsite consultant anaesthetic or surgical staff (17:00 to 08:00).

Conclusion

This study highlights the anticipated medical emergencies for a 23-hour procedural unit and is of particular interest for evaluation by other short stay surgical, outpatient procedural, or rural hospital surgical units with limited after hours on-site critical care support.

Type of Track and Trigger system and incidence of in-hospital cardiac arrest: an observational registry-based study

BACKGROUND

Failure to recognise and respond to patient deterioration on hospital wards is a common cause of healthcare-related harm. If patients are not rescued and suffer a cardiac arrest as a result then only around 15% will survive. Track and Trigger systems have been introduced into the NHS to improve both identification and response to such patients. This study examines the association between the type of Track & Trigger System (TTS) (National Early Warning Score (NEWS) versus non-NEWS) and the mode of TTS (paper TTS versus electronic TTS) and incidence of in-hospital ward-based cardiac arrests (IHCA) attended by a resuscitation team.

METHODS

TTS type and mode was retrospectively collected at hospital level from 106 NHS acute hospitals in England between 2009 to 2015 via an organisational survey. Poisson regression and logistic regression models, adjusted for case-mix, temporal trends and seasonality were used to determine the association between TTS and hospital-level ward-based IHCA and survival rates.

RESULTS

The NEWS was introduced in England in 2012 and by 2015, three-fifths of hospitals had adopted it. One fifth of hospitals had instituted an electronic TTS by 2015. Between 2009 and 2015 the incidence of IHCA fell. Introduction or use of NEWS in a hospital was associated with a reduction of 9.4% in the rate of ward-based IHCA compared to non-NEWS systems (incidence rate ratio 0.906, p < 0.001). The use of an electronic TTS was also associated with a reduction of 9.8% in the rate of IHCA compared with paper-based TTS (incidence rate ratio 0.902, p = 0.009). There was no change in hospital survival.

CONCLUSIONS

The introduction of standardised TTS and electronic TTS have the potential to reduce ward-based IHCA. This is likely to be via a range of mechanisms from early intervention to institution of treatment limits. The lack of association with survival may reflect the complexity of response to triggering of the afferent arm of the rapid response system.

Diurnal Variation in Medical Emergency Team Calls at a Tertiary Care Children's Hospital

Medical emergency teams (METs) bring critical care expertise to the bedsides of hospital ward patients who may be deteriorating. Diurnal variation in MET activation rates may identify inconsistencies in the detection of patients needing intervention. We aimed to determine whether such variation exists at our tertiary care children's hospital.

Methods

In this retrospective cohort study, we collected data including date and time of MET and disposition following MET for all inpatients at Cincinnati Children's Hospital Medical Center with a MET call between January 2008 and May 2014. The analysis compared the MET rate between days and nights, weekdays and weekends, and before and after nursing shift change.

Results

The number of METs per hour varied throughout the day. More METs were called during the day than at night (0.7 calls/shift ± 0.95 vs 0.6 ± 0.9, P < 0.001). There were also more METs per day on weekdays than weekends (1.4 ± 1 calls/d vs 1.2 ± 1, P < 0.001). Daytime METs were more likely to lead to transfer to the intensive care unit or operating room than those called at night (61.9% vs. 52.9%, P < 0.001). MET activation rates did not differ significantly in the 2 hours before nursing shift change compared to the 2 hours after.

Conclusions

At our large tertiary care children's hospital, there are both diurnal variations and variations across weekdays versus weekends in the MET activation rate. This difference may indicate variations in our ability to detect deteriorating patients on the wards and be further studied.

Insight into hospital ward nurses' concerns about patient health and the corresponding Medical Emergency Team nurse response

AIM

This study aims to understand the concerns of nurses when making MET calls which did not fulfil the vital sign criteria, and the MET nurses subsequent responses to these calls.

METHODS

This was a retrospective report-based study. Research material included nursing reports and MET forms related to MET calls made due to nurses' concern. Inductive content analysis was used to identify observations, which were then quantified based on the research material.

FINDINGS

From a total of 546 MET calls, 39 visits (7%) were due to nurses' concern. In these 39 visits, the vital sign criteria did not reach the alert threshold, but nurses made the call due to subjective worry. In 13% of visits, the alert concern was inadequate contact with the doctor. MET nurses responded to the alert by providing clinical and indirect nursing; more specifically, they performed examinations and nursing interventions and collaborated with other professionals.

CONCLUSION

A nurse's worry is influenced by subjective changes in the patient's condition or an inadequate doctor's response rather than objective physiological measurements. A MET nurse's ability to assess patient condition, respond to nurses' calls, and acknowledge justified alerts help MET nurses support concerned nurses and encourage them to contact the MET if necessary.

Ward visits- one essential step in intensive care follow-up. An interview study with critical care nurses' and ward nurses'

OBJECTIVE

The aim of this study was to describe critical care nurses' and ward nurses' perceptions of the benefits and challenges with a nurse-led follow-up service for intensive care-survivors at general wards.

BACKGROUND

Patients recently transferred from intensive care to the general ward are still vulnerable and require complex care. There are different models of intensive care follow-up services and some include ward visits after transfer from intensive care. Research methodology/design: This study had a qualitative design. Data from 13 semi-structured interviews with Swedish critical care nurses and ward nurses were analysed using qualitative content analysis.

FINDINGS

The findings consisted of one theme, namely, "Being a part of an intra-organisational collaboration for improved quality of care", and four subthemes: "Provides additional care for the vulnerable patients, "Strengthens ward-based critical care", "Requires coordination and information", and "Creates an exchange of knowledge". The nurse-led follow-up service detected signs of deterioration and led to better quality of care. However, shortage of time, lack of interaction, feedback and information about the function of the follow-up service led to problems.

CONCLUSION

The findings indicate that ward visits should be included in the intensive care follow-up service. Furthermore, intra-organisational collaboration seems to be essential for intensive care survivors' quality of care.

Rapid response systems

INTRODUCTION

Rapid response systems are commonly employed by hospitals to identify and respond to deteriorating patients outside of the intensive care unit. Controversy exists about the benefits of rapid response systems.

AIMS

We aimed to review the current state of the rapid response literature, including evolving aspects of afferent (risk detection) and efferent (intervention) arms, outcome measurement, process improvement, and implementation.

DATA SOURCES

Articles written in English and published in PubMed.

RESULTS

Rapid response systems are heterogeneous, with important differences among afferent and efferent arms. Clinically meaningful outcomes may include unexpected mortality, in-hospital cardiac arrest, length of stay, cost, and processes of care at end of life. Both positive and negative interventional studies have been published, although the two largest randomized trials involving rapid response systems - the Medical Early Response and Intervention Trial (MERIT) and the Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients (EPOCH) trial - did not find a mortality benefit with these systems, albeit with important limitations. Advances in monitoring technologies, risk assessment strategies, and behavioral ergonomics may offer opportunities for improvement.

CONCLUSIONS

Rapid responses may improve some meaningful outcomes, although these findings remain controversial. These systems may also improve care for patients at the end of life. Rapid response systems are expected to continue evolving with novel developments in monitoring technologies, risk prediction informatics, and work in human factors.

Communication and general concern criterion prior to activation of the rapid response team: a grounded theory

Objective Patients commonly show signs and symptoms of deterioration for hours or days before cardiorespiratory arrest. Rapid response teams (RRT) were created to improve recognition and response to patient deterioration in these situations. Activation criteria include vital signs or 'general concern' by a clinician or family member. The general concern criterion for RRT activation accounts for nearly one-third of all RRT activity, and although it is well established that communication deficits between staff can contribute to poorer outcomes for patients, there is little evidence pertaining to communication and its effects on the general concern RRT activation. Thus, the aim of the present study was to develop a substantive grounded theory related to the communication process between clinicians that preceded the activation of an RRT when general concern criterion was used. Methods Qualitative grounded theory involved collection of three types of data details namely personal notes from participants in focus groups with white board notes from discussions and audio recordings of the focus groups sessions. Focus groups were conducted with participants exploring issues associated with clinician communication and how it related to the activation of an RRT using the general concern criterion. Results The three main phases of coding (i.e. open, axial and selective coding) analysis identified 322 separate open codes. The strongest theme contributed to a theory of ineffective communication and decreased psychological safety, namely that 'In the absence of effective communication there is a subsequent increase in anxiety, fear or concern that can be directly attributed to the activation of an RRT using the 'general concern' criterion'. The RRT filled cultural and process deficiencies in the compliance with an escalation protocol. Issues such as 'not for resuscitation documentation' and 'inability to establish communication with and between medical or nursing personnel' rated highly and contributed to the debate. Conclusions This study highlighted that in the surveillance and management of the deteriorating patient and in the absence of effective communication there is a subsequent increase in anxiety, fear or concern that can be directly attributed to the activation of an RRT for the 'general concern' calling criteria. What is known about the topic? Deficiencies in collaboration and communication between healthcare professionals (HCPs) increase the stress and anxiety of healthcare staff and correspond to poorer outcomes for patients. The RRT can be activated as a 'general concern RRT' without observation of physiological derangements if staff are concerned about a patient's condition, allowing for assistance from a skilled critical care team at the patient's bedside. There are limited data on how poor communication affects the frequency of activation of general concern RRTs. What does this paper add? This study shows that poor communication between health professionals increases staff levels of anxiety and concern. In addition, the RRT system is being used to fill deficiencies in many other hospital processes, including end-of-life discussions. The deficiencies in hospital processes contribute to poor communication and increased levels of concern with this study demonstrating a direct link between a clinician's level of anxiety/concern and the 'general concern' activation category for the RRT system. What are the implications for practitioners? The present study highlights the importance of effective communication strategies between HCPs to improve patient safety and quality of care. The study also highlights the expanding role of the RRT in hospitals, which has implications for hospital policy makers with regard to future funding and resource allocation. Finally, many of the concerns raised in the present study by the focus groups have been addressed by recent measures introduced through the Australian Commission on Safety and Quality in Health Care (e.g. rapid detection and response observation charts and Introduction, Situation, Background, Assessment and Recommendation [ISBAR] style of communication) with these measures supported by the findings of the present study.

Improving the Quality of Ward-based Surgical Care With a Human Factors Intervention Bundle

OBJECTIVE

This study aimed to explore the impact of a human factors intervention bundle on the quality of ward-based surgical care in a UK hospital.

SUMMARY OF BACKGROUND DATA

Improving the culture of a surgical team is a difficult task. Engagement with stakeholders before intervention is key. Studies have shown that appropriate supervision can enhance surgical ward safety.

METHODS

A pre-post intervention study was conducted. The intervention bundle consisted of twice-daily attending ward rounds, a "chief resident of the week" available at all times on the ward, an escalation of care protocol and team contact cards. Twenty-seven junior and senior surgeons completed validated questionnaires assessing supervision, escalation of care, and safety culture pre and post-intervention along with interviews to further explore the impact of the intervention. Patient outcomes pre and postintervention were also analyzed.

RESULTS

Questionnaires revealed significant improvements in supervision postintervention (senior median pre 5 vs post 7, P = 0.002 and junior 4 vs 6, P = 0.039) and senior surgeon approachability (junior 5 vs 6, P = 0.047). Both groups agreed that they would feel safer as a patient in their hospital postintervention (senior 3 vs 4.5, P = 0.021 and junior 3 vs 4, P = 0.034). The interviews confirmed that the safety culture of the department had improved. There were no differences in inpatient mortality, cardiac arrest, reoperation, or readmission rates pre and postintervention.

CONCLUSION

Improving supervision and introducing clear protocols can improve safety culture on the surgical ward. Future work should evaluate the effect these measures have on patient outcomes in multiple institutions.

The impact of delayed rapid response call activation on patient outcomes

PURPOSE

To investigate the impact of delay in rapid response call (RRC) activation on Hospital mortality.

MATERIALS AND METHODS

This study was conducted in a university affiliated hospital providing medical, surgical, mental health, maternity, and pediatric services. RRCs were considered delayed if RRC activation was delayed by ≥15min. The primary outcome measure was in-hospital mortality. Secondary outcomes included hospital length of stay (LOS), requirement of ICU admission, as well as requirement of mechanical ventilation and ICU LOS for patients requiring ICU admission.

RESULTS

A total of 826 RRCs occurred in 629 patient admissions. A quarter of all RRCs were delayed by ≥15min, with a median delay of 1h and 20min. Patients with a delayed RRC had significantly higher in-hospital mortality (34.7% vs. 21.2%; p=0.001,) and significantly longer hospitalizations (11.6 vs. 8.4days; p=0.036). After adjusting for confounders, RRC activation was independently associated with increased in-hospital mortality (OR=1.79; 95% CI=1.17-2.72: p=0.007).

CONCLUSIONS

A delay of ≥15min was associated with significantly increased in-hospital mortality and longer hospitalization. The factors contributing to the observed increase in mortality with delayed RRCs require further exploration.

Impact of implementation of the National Early Warning Score on patients and staff

The National Early Warning Score (NEWS) has been criticized for increasing workload and decreasing attention to signs of deterioration. This study highlighted the significant mortality of ward patients referred to critical care, and showed that the NEWS identified high-risk patients without increasing workload or worsening outcomes.

A Comparison of the Ability of the Physiologic Components of Medical Emergency Team Criteria and the U.K. National Early Warning Score to Discriminate Patients at Risk of a Range of Adverse Clinical Outcomes

OBJECTIVE

To compare the ability of medical emergency team criteria and the National Early Warning Score to discriminate cardiac arrest, unanticipated ICU admission and death within 24 hours of a vital signs measurement, and to quantify the associated workload.

DESIGN

Retrospective cohort study.

SETTING

A large U.K. National Health Service District General Hospital.

PATIENTS

Adults hospitalized from May 25, 2011, to December 31, 2013.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We applied the National Early Warning Score and 44 sets of medical emergency team criteria to a database of 2,245,778 vital signs sets (103,998 admissions). The National Early Warning Score's performance was assessed using the area under the receiver-operating characteristic curve and compared with sensitivity/specificity for different medical emergency team criteria. Area under the receiver-operating characteristic curve (95% CI) for the National Early Warning Score for the combined outcome (i.e., death, cardiac arrest, or unanticipated ICU admission) was 0.88 (0.88-0.88). A National Early Warning Score value of 7 had sensitivity/specificity values of 44.5% and 97.4%, respectively. For the 44 sets of medical emergency team criteria studied, sensitivity ranged from 19.6% to 71.2% and specificity from 71.5% to 98.5%. For all outcomes, the position of the National Early Warning Score receiver-operating characteristic curve was above and to the left of all medical emergency team criteria points, indicating better discrimination. Similarly, the positions of all medical emergency team criteria points were above and to the left of the National Early Warning Score efficiency curve, indicating higher workloads (trigger rates).

CONCLUSIONS

When medical emergency team systems are compared to a National Early Warning Score value of greater than or equal to 7, some medical emergency team systems have a higher sensitivity than National Early Warning Score values of greater than or equal to 7. However, all of these medical emergency team systems have a lower specificity and would generate greater workloads.

Risk for Cardiorespiratory Instability Following Transfer to a Monitored Step-Down Unit

BACKGROUND

Hospitalized patients who develop at least one instance of cardiorespiratory instability (CRI) have poorer outcomes. We sought to describe the admission characteristics, drivers, and time to onset of initial CRI events in monitored step-down unit (SDU) patients.

METHODS

Admission characteristics and continuous monitoring data (frequency 1/20 Hz) were recorded in 307 subjects. Vital sign deviations beyond local instability trigger threshold criteria, with a tolerance of 40 s and cumulative duration of 4 of 5 min, were classified as CRI events. The CRI driver was defined as the first vital sign to cross a threshold and meet persistence criteria. Time to onset of initial CRI was the number of days from SDU admission to initial CRI, and duration was length of the initial CRI epoch.

RESULTS

Subjects transferred to the SDU from units with higher monitoring capability were more likely to develop CRI (CRI n = 133 [44%] vs no CRI n = 174 [31%] P = .042). Time to onset varied according to the CRI driver. Subjects with at least one CRI event had a longer hospital stay (CRI 11.3 ± 10.2 d vs no CRI 7.8 ± 9.2 d, P < .001) and SDU stay (CRI 6.1 ± 4.9 d vs no CRI 3.5 ± 2.9 d, P < .001). First events were more often due to S_pO2 , whereas breathing frequency was the most common driver of all CRI.

CONCLUSIONS

Initial CRI most commonly occurred due to S_pO2 and was associated with prolonged SDU and hospital stay. Findings suggest the need for clinicians to more closely monitor SDU patients transferred from an ICU and parameters (S_pO2 , breathing frequency) that more commonly precede CRI events.

Rapid Response Teams: Is it Time to Reframe the Questions of Rapid Response Team Measurement?

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.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predicting Patients at Risk of Early Postoperative Adverse Events

Adverse events after surgery are common. Identification of markers of at-risk patients may facilitate efficient and effective perioperative resource allocation. This pilot study aimed to identify simple preoperative factors associated with postoperative adverse events. In 1291 surgical patients, the relationship between patient and surgical factors and adverse events in the post-anaesthesia care unit was examined using binomial logistic regression analysis. Adverse events in the postoperative care unit were common, including desaturation (13.6%), hypotension (5.8%) and apnoea (5.5%), with 19.9% of cases requiring attendance by an anaesthetist to manage unexpected complications. Average length-of-stay in the post-anaesthesia care unit was 120 minutes and prolonged stay for medical reasons was common. A number of patient and surgical factors, including surgical complexity, preoperative arrhythmia, previous anaesthetic issues and heart failure were strongly associated with these adverse events. Areas under receiver operating characteristic curves ranged from 0.63 to 0.80. Patients with adverse events in the post-anaesthesia care unit appeared to have a higher risk of intervention in postoperative wards from a medical emergency or intensive care unit team. Our preliminary findings suggest that preoperative identification of key factors may have utility in determining risk of early postoperative problems and hence, aid perioperative planning.

Rapid-response systems as a patient safety strategy: a systematic review

Rapid-response systems (RRSs) are a popular intervention in U.S. hospitals and are supported by accreditors and quality improvement organizations. The purpose of this review is to evaluate the effectiveness and implementation of these systems in acute care settings. A literature search was performed between 1 January 2000 through 30 October 2012 using PubMed, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies published in any language evaluating outcome changes that occurred after implementing an RRS and differences between groups using and not using an RRS (effectiveness) or describing methods used by RRSs (implementation) were reviewed. A single reviewer (checked by a second reviewer) abstracted data and rated study quality and strength of evidence. Moderate-strength evidence from a high-quality meta-analysis of 18 studies and 26 lower-quality before-and-after studies published after that meta-analysis showed that RRSs are associated with reduced rates of cardiorespiratory arrest outside of the intensive care unit and reduced mortality. Eighteen studies examining facilitators of and barriers to implementation suggested that the rate of use of RRSs could be improved.

A review of rapid response team activation parameters in New Zealand hospitals

OBJECTIVE

To review current systems for recognising and responding to clinically deteriorating patients in all New Zealand public hospitals.

DESIGN

A cross-sectional study of recognition and response systems in all New Zealand public hospitals was conducted in October 2011. Copies of all current vital sign charts and/or relevant policies were requested. These were examined for vital sign based recognition and response systems. The charts or policies were also used to determine the type of system in use and the vital sign parameters and trigger thresholds that provoke a call to the rapid response team.

SETTING

All New Zealand District Health Boards (DHBs).

MAIN OUTCOME MEASURES

Physiological parameters used to trigger rapid response, the weighting of any early warning score assigned to them, type of system used, values of physiological derangement that trigger maximal system response.

RESULTS

All DHBs use aggregate scoring systems to assess deterioration and respond. A total of 9 different physiological parameters were scored with most charts (21%) scoring 6 different parameters. All scored respiratory rate, heart rate, systolic blood pressure and conscious level. 86% scored oliguria, 14% polyuria, 33% oxygen saturation and 24% oxygen administration. All systems used either aggregate scores or a single extreme parameter to elicit a maximal system response. The extremes of physiological derangement to which scores were assigned varied greatly with bradypnoea having the greatest range for what was considered grossly abnormal.

CONCLUSION

A large variance exists in the criteria used to detect deteriorating patients within New Zealand hospitals. Standardising both the vital signs chart and escalation criteria is likely to be of significant benefit in the early detection of and response to patient deterioration.

Application of Medical Information Systems for the detection of high risk patients: rapid care alerts. Pilot study of the ARA-Son Llàtzer Project

OBJECTIVE

To describe the implementation of a Medical Information System (MIS) in the Critical Care Departament (CCD).

DESIGN

A prospective observational cohort study was carried out.

SETTING

Clinical and Surgical wards in Son Llàtzer Hospital.

PATIENTS

Patients with criteria of rapid care alert (RCA) without treatment, cardiac arrest (CA), and unexpected ward deaths (UWD), during 2010.

MAIN VARIABLES

Age, sex, nursing shift, nursing alert, vital signs, unplanned admission to intensive care, CA, UWD and death.

RESULTS

The MIS detected 9647 episodes with RCA signs in 4020 patients (26.4 episodes/day). A total of 8547 episodes were reviewed. Sixty-five patients required rapid response by the intensive care staff; 61.5% were detected in the afternoon shift (15:00 a 22:00), and 61.5% were admitted to the CCD. Diminished consciousness (DC) and respiratory failure were the most frequent problems. The sepsis rate was 23%. We reviewed 45 CA and 35 UWD. Of the total cases of CA, 33 patients died (73.3%) and 66.7% had criteria of untreated RCA. Monitoring (P<.05) and rhythms amenable to defibrillation (P<.002) were associated to survival. As regards the UWD, 75% had criteria of untreated RCA, and 40.6% presented diminished consciousness. In the last 6 months there was a significant reduction in UWD (P=.01)

CONCLUSIONS

The MIS could be a complimentary tool in the activity of the CCD to improve the prognosis of hospitalized patients.

Rapid response systems: a prospective study of response times

PURPOSE

The purpose of the study was to evaluate the time taken for delivery of each component of care following patient deterioration and to assess the effect on response times of strategies implemented to improve the system.

METHODS

A model identifying the sequence of organizational responses following a patient's unexpected clinical deterioration was developed. The time to key events and interventions from initial deterioration was measured for 3 months in 2005 and again in 2006 at a tertiary care hospital with a rapid response team (RRT) in place. Strategies to improve compliance with the RRT system were introduced between the 2 periods.

RESULTS

The number of acute deterioration episodes identified increased (61 episodes in 2005; 154 episodes in 2006), but there was no improvement in response times. The 2 components contributing most frequently to delays were the time for nursing staff to call for assistance and, where needed, for physicians to call for higher-level care. Overall, 26% of episodes in 2006 and 30% in 2005 did not receive medical attention within 30 minutes of acute deterioration.

CONCLUSIONS

Significant delays in responding to acute deterioration persist despite strategies to facilitate the functioning of the RRT system. Simple strategies such as policy directives are not sufficient to effect change in complex health care systems.