1
|
Piasecki RJ, Himmelfarb CRD, Gleason KT, Justice RM, Hunt EA. The associations between rapid response systems and their components with patient outcomes: A scoping review. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2023; 5:100134. [PMID: 38125770 PMCID: PMC10732356 DOI: 10.1016/j.ijnsa.2023.100134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Rebecca J. Piasecki
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
| | | | - Kelly T. Gleason
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
| | | | - Elizabeth A. Hunt
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
| |
Collapse
|
2
|
Byrne G, Ennis S, Barnes AM, Morrison P, Connors S, Quirke MB. Triggers and Interventions of Patients Who Require Medical Emergency Team Reviews: A Cross-Sectional Analysis of Single Versus Multiple Reviews. Crit Care Nurse 2021; 41:e1-e10. [PMID: 34333613 DOI: 10.4037/ccn2021407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Medical emergency teams constitute part of the escalation protocol of early warning systems in many hospitals. The literature indicates that medical emergency teams may reduce hospital mortality and cardiac arrest. A greater understanding of pathways of patients who experience multiple medical emergency team reviews will inform clinical decision-making. OBJECTIVES To explore differences between patients who require a single medical emergency team review and those who require multiple reviews, and to identify any differences between patients who were reviewed only once during admission and patients who required multiple reviews. METHODS Data for this retrospective cross-sectional review, including demographic data, call triggers, outcomes, and interventions, were routinely collected from January 2013 through December 2015. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) collaborative's cross-sectional studies checklist (version 4). RESULTS Of 54 787 admitted patients, 1274 (2%) required a call to a medical emergency team; of those, 260 patients (20%) needed multiple calls. Patients requiring multiple calls demonstrated higher mortality (odds ratio, 1.49 [95% CI, 1.12-1.98]). A logistic regression model identified surgical patients and those receiving antibiotics and respiratory interventions at the first medical emergency team review as being more likely to require multiple reviews. Patients transferred to a higher level of care after the first review were less likely to require another review. CONCLUSIONS Patients requiring multiple medical emergency team reviews have higher mortality. Surgical patients have a higher risk of requiring multiple reviews. Hospitals need to include more details on surgical patients when auditing medical emergency team activation.
Collapse
Affiliation(s)
- Gobnait Byrne
- Gobnait Byrne is Director, Trinity Centre for Practice and Health-care Innovation, and an assistant professor, School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Shauna Ennis
- Shauna Ennis is Head of Learning and Development, Tallaght University Hospital, Dublin, Ireland
| | - Anne Marie Barnes
- Anne Marie Barnes is the Emergency Response System Coordinator, Tallaght University Hospital
| | - Patricia Morrison
- Patricia Morrison is the Assistant Director of Nursing and Lead Assistant Director of Nursing for the Perioperative Directorate, Tallaght University Hospital
| | - Siobhan Connors
- Siobhan Connors is a critical care outreach nurse, Tallaght University Hospital
| | - Mary B Quirke
- Mary B. Quirke is a research fellow, Trinity Centre for Practice and Healthcare Innovation, School of Nursing and Midwifery, Trinity College Dublin
| |
Collapse
|
3
|
Gao W, Zhang YP, Jin JF. Poor outcomes of delirium in the intensive care units are amplified by increasing age: A retrospective cohort study. World J Emerg Med 2021; 12:117-123. [PMID: 33728004 DOI: 10.5847/wjem.j.1920-8642.2021.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Delirium in patients in intensive care units (ICUs) is an acute disturbance and fluctuation of cognition and consciousness. Though increasing age has been found to be related to ICU delirium, there is limited evidence of the effect of age on delirium outcomes. The aim of this study is to investigate the relationship between age categories and outcomes among ICU delirium patients. METHODS Data were extracted from the electronic ICU (eICU) Collaborative Research Database with records from 3,931 patients with delirium. Patients were classified into non-aged (<65 years), young-old (65-74 years), middle-old (75-84 years), and very-old (≥85 years) groups. A Cox regression model was built to examine the role of age in death in ICU and in hospital after controlling covariates. RESULTS The sample included 1,667 (42.4%) non-aged, 891 (22.7%) young-old, 848 (21.6%) middle-old, and 525 (13.3%) very-old patients. The ICU mortality rate was 8.3% and the hospital mortality rate was 15.4%. Compared with the non-aged group, the elderly patients (≥65 yeras) had higher mortality at ICU discharge (χ2 =13.726, P=0.001) and hospital discharge (χ 2=56.347, P<0.001). The Cox regression analysis showed that age was an independent risk factor for death at ICU discharge (hazard ratio [HR]=1.502, 1.675, 1.840, 95% confidence interval [CI] 1.138-1.983, 1.250-2.244, 1.260-2.687; P=0.004, 0.001, 0.002 for the young-, middle- and very-old group, respectively) as well as death at hospital discharge (HR=1.801, 2.036, 2.642, 95% CI 1.454-2.230, 1.638-2.530, 2.047-3.409; all P<0.001). CONCLUSIONS The risks of death in the ICU and hospital increase with age among delirious patients.
Collapse
Affiliation(s)
- Wen Gao
- Nursing Department, School of Medicine, Zhejiang University, Hangzhou 310058, China.,Nursing Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Yu-Ping Zhang
- Nursing Department, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Jing-Fen Jin
- Nursing Department, School of Medicine, Zhejiang University, Hangzhou 310058, China
| |
Collapse
|
4
|
Allen J, Orellana L, Jones D, Considine J, Currey J. Associations between patient and system characteristics and MET review within 48 h of admission to a teaching hospital: A retrospective cohort study. Eur J Intern Med 2019; 66:62-68. [PMID: 31155230 DOI: 10.1016/j.ejim.2019.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/21/2019] [Accepted: 05/20/2019] [Indexed: 10/26/2022]
Abstract
The Medical Emergency Team (MET) has enhanced the recognition and response to clinical deterioration in acute healthcare. However, patients reviewed by the MET are at increased risk of in-hospital death. Identifying patients at risk of deterioration may improve patient outcomes. AIM: To identify patient demographic, medical characteristics and healthcare systems and processes at the time of admission (baseline), associated with Medical Emergency Team (MET) review within 48 h (MET-48 h) of admission. METHODS: Single-site, year-long, retrospective cohort comprising patients admitted for at least 24 h, using routinely collected hospital data. A three-stage modelling approach was used to identify baseline factors associated with MET-48 h RESULTS: The study included 15,695 patients with mean age 62.1 years (SD 19.6), male (53.5%), born in Australia or New Zealand (60.9%) and 51.6% held a low-income concession card. A total of 4.3% of patients received a MET review within 48 h of admission. Variables independently associated with MET-48 h in a fully adjusted logistic model included age of 80 years or more (OR = 1.37); ≥3 previous emergency admissions (OR = 1.59); Charlson Comorbidity Index 1 or 2 (OR = 1.47), or ≥ 3 (OR = 1.99); history of alcohol-related behaviour concerns (OR = 2.04), chronic heart failure (OR = 1.48); chronic obstructive pulmonary disease (OR = 1.35); admission for colorectal (OR = 2.66) or upper gastro-intestinal (OR = 1.94) surgery, respiratory or tracheostomy (OR = 2.24); immunology and infections (OR = 1.90); emergency admission (OR = 1.36); admission at night (OR = 1.74), or summer (OR = 1.41) CONCLUSIONS: This is the first study to demonstrate the potential to predict clinical deterioration using data that is readily accessible at the time of admission to hospital.
Collapse
Affiliation(s)
- Joshua Allen
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Geelong, VIC 3220, Australia.
| | - Liliana Orellana
- Deakin University, Biostatistics Unit, Faculty of Health, Geelong, VIC 3220, Australia.
| | - Daryl Jones
- DEPM Monash University, Level 6 The Alfred Centre (Alfred Hospital), 99 Commercial Road, Melbourne, Victoria 3004, Australia; Department of Surgery University of Melbourne, Austin Hospital, Studley Road Heidelberg, Victoria 3084, Australia; Intensive Care Unit, Austin Hospital, Studley Road Heidelberg, Victoria 3084, Australia.
| | - Julie Considine
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Geelong, VIC 3220, Australia; Centre for Quality and Patient Safety Research - Eastern Health Partnership, 2/5 Arnold Street, Box Hill, VIC 3128, Australia.
| | - Judy Currey
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Geelong, VIC 3220, Australia.
| |
Collapse
|
5
|
Malycha J, Bonnici T, Clifton DA, Ludbrook G, Young JD, Watkinson PJ. Patient centred variables with univariate associations with unplanned ICU admission: a systematic review. BMC Med Inform Decis Mak 2019; 19:98. [PMID: 31092256 PMCID: PMC6521409 DOI: 10.1186/s12911-019-0820-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 05/02/2019] [Indexed: 01/30/2023] Open
Abstract
Background Multiple predictive scores using Electronic Patient Record data have been developed for hospitalised patients at risk of clinical deterioration. Methods used to select patient centred variables for inclusion in these scores varies. We performed a systematic review to describe univariate associations with unplanned Intensive Care Unit (ICU) admission with the aim of assisting model development for future scores that predict clinical deterioration. Methods Data sources were MEDLINE, EMBASE, CINAHL, CENTRAL and the Cochrane Database of Systematic Reviews. Included studies were published since 2000 describing an association between patient centred variables and unplanned ICU admission determined using univariate analysis. Two authors independently screened titles, abstracts and full texts against inclusion and exclusion criteria. DistillerSR (Evidence Partners, Canada, Ottawa, Ontario) software was used to manage the data and identify duplicate search results. All screening and data extraction forms were implemented within DistillerSR. Study quality was assessed using an adapted version of the Newcastle-Ottawa Scale. Variables were analysed for strength of association with unplanned ICU admission. Results The database search yielded 1520 unique studies; 1462 were removed after title and abstract review; 57 underwent full text screening; 16 studies were included. One hundred and eighty nine variables with an evaluated univariate association with unplanned ICU admission were described. Discussion Being male, increasing age, a history of congestive cardiac failure or diabetes, a diagnosis of hepatic disease or having abnormal vital signs were all strongly associated with ICU admission. Conclusion These findings will assist variable selection during the development of future models predicting unplanned ICU admission. Trial registration This study is a component of a larger body of work registered in the ISRCTN registry (ISRCTN12518261). Electronic supplementary material The online version of this article (10.1186/s12911-019-0820-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- James Malycha
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
| | - Timothy Bonnici
- Department of Critical Care, University College London Hospitals Foundation Trust, Maple Link Bridge, University College Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - David A Clifton
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7DC, UK
| | - Guy Ludbrook
- Faculty of Health and Medical Science, University of Adelaide, North Terrace, AHMS Floor 8, Adelaide, 5000, Australia
| | - J Duncan Young
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Peter J Watkinson
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| |
Collapse
|
6
|
Huang W, Cohen AT, Martin AC, Anderson FA. Magnitude of Venous Thromboembolism Risk in US Hospitals: Impact of Evolving National Guidelines for Prevention of Venous Thromboembolism. Am J Med 2019; 132:588-595. [PMID: 30658087 DOI: 10.1016/j.amjmed.2018.12.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 12/19/2018] [Accepted: 12/19/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The annual number of US hospital discharges at risk for venous thromboembolism and the impact of evolving American College of Chest Physicians (ACCP) consensus guidelines for prevention of venous thromboembolism are unknown. METHODS Three risk-assessment algorithms based on 2004, 2008, and 2012 ACCP guidelines for prevention of venous thromboembolism were applied to the 2014 US National Inpatient Sample to derive estimates of the annual number of US inpatients at risk for venous thromboembolism. RESULTS Of 35.4 million discharges from US acute-care hospitals in 2014, 25.3 million (71%) met study inclusion criteria of age ≥18 years and length of stay (LOS) ≥2 days. Among 7.5 million patients who underwent a procedure in an operating room, more than 4.4 million (59%) were at ACCP-defined risk for venous thromboembolism, irrespective of which version of the ACCP guidelines applied. With an additional 8.4/8.5/7.3 million eligible discharges meeting criteria for venous thromboembolism prophylaxis due to medical risk factors, the total annual numbers of inpatients at risk for venous thromboembolism were 12.8/12.9/11.7 million according to 2004/2008/2012 ACCP guidelines, respectively. CONCLUSIONS Over half of adult patients who had an LOS ≥2 days in US acute-care hospitals met ACCP criteria for consideration of venous thromboembolism prophylaxis based on risk factors associated with surgery or acute medical illness. These data provide an objective basis for estimating the potential impact of venous thromboembolism prevention on patient care, together with associated costs, risks, and benefits.
Collapse
Affiliation(s)
- Wei Huang
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's, King's and St. Thomas' School of Medicine, London, UK
| | - Anne-Céline Martin
- Department of Haematological Medicine, Guy's, King's and St. Thomas' School of Medicine, London, UK; Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche (UMR)-S1140, Faculté de Pharmacie, Université Paris Descartes, France
| | - Frederick A Anderson
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester.
| |
Collapse
|
7
|
Pearse W, Oprescu F, Endacott J, Goodman S, Hyde M, O'Neill M. Advance care planning in the context of clinical deterioration: a systematic review of the literature. Palliat Care 2019; 12:1178224218823509. [PMID: 30718959 PMCID: PMC6348551 DOI: 10.1177/1178224218823509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/29/2018] [Indexed: 11/16/2022] Open
Abstract
Background: A Rapid Response Team can respond to critically ill patients in hospital to prevent further deterioration and unexpected deaths. However, approximately one-third of reviews involve a patient approaching the end-of-life. It is not well understood whether patients have pre-existing advance care plans at the time of significant clinical deterioration requiring Rapid Response Team review. Nor is it understood whether such critical events prompt patients, their families and treating teams to discuss advance care planning and consider referral to specialist palliative care services. Aim and design: This systematic review examined advance care planning with patients who experience significant clinical deterioration in hospital and require Rapid Response Team review. The prevalence of pre-existing advance directives, whether this event prompts end-of-life discussions, the provision of broader advance care planning and referral to specialist palliative care services was examined. Data sources: Three electronic databases up to August 2017 were searched, and a manual review of article reference lists conducted. Quality of studies was appraised by the first and fourth authors. Results: Of the 324 articles identified through database searching, 31 met the inclusion criteria, generating data from 47,850 patients. There was a low prevalence of resuscitation orders and formal advance directives prior to Rapid Response Team review, with subsequent increases in resuscitation and limitations of medical treatment orders, but not advance directives. There was high short- and long-term mortality following review, and low rates of palliative care referral. Conclusions: The failure of patients, their families and medical teams to engage in advance care planning may result in inappropriate Rapid Response Team review that is not in line with patient and family priorities and preferences. Earlier engagement in advance care planning may result in improved person-centred care and referral to specialist palliative care services for ongoing management.
Collapse
Affiliation(s)
- Wendy Pearse
- Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia School of Health and Sports Sciences, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| | - Florin Oprescu
- School of Health and Sport Sciences, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| | - John Endacott
- Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia
| | - Sarah Goodman
- Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia
| | - Mervyn Hyde
- School of Education, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| | - Maureen O'Neill
- School of Law, University of the Sunshine Coast, Maroochydore DC, QLD, Australia
| |
Collapse
|
8
|
Giannasi SE, Venuti MS, Midley AD, Roux N, Kecskes C, San Román E. Mortality risk factors in elderly patients in intensive care without limitation of therapeutic effort. Med Intensiva 2017; 42:482-489. [PMID: 29289386 DOI: 10.1016/j.medin.2017.10.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 10/24/2017] [Accepted: 10/26/2017] [Indexed: 01/22/2023]
Abstract
OUTCOME To determine mortality prognostic factors in elderly patients who are admitted to intensive care units (ICUs) due to acute critical illness. DESIGN A prospective cohort study was carried out. SETTING A polyvalent Intensive Care Unit at a University Hospital in Argentina. PATIENTS OR PARTICIPANTS We included 249 patients over 65years of age who were consecutively admitted to the ICU and required mechanical ventilation for more than 48hours, between January 2011 and December 2012. Patients with degenerative neurological disease, limitation of therapeutic effort or on chronic mechanical ventilation were excluded. PRINCIPAL VARIABLES OF INTEREST In-hospital mortality, comorbidity (Charlson index), APACHEII score, and pre-acute illness status were recorded: nutritional status (subjective global assessment), functionality (activities of daily living [ADL] and Barthel index), cognitive abilities (Short Reporting Questionnaire on Cognitive Decline in the Elderly [S_IQCODE]) and quality of life (EQ-5D). RESULTS The in-hospital mortality rate was 52%. Logistic regression analysis, after adjusting for APACHEII score and age, identified the following independent variables associated to mortality: male gender (OR: 2.46, 95%CI: 1.37-4.42), moderate malnutrition (OR: 2.07, 95%CI: 1.09-3.94), severe malnutrition (OR: 2.20, 95%CI: 1.06-4.59), and ADL<6 (OR: 2.35, 95%CI: 1.16-4.75). CONCLUSIONS In our study, chronological age was not associated to in-hospital mortality. However, loss of functional independence (assessed by ADL) and malnourishment were shown to be strong prognostic factors; knowing these baseline characteristics from ICU admission would be useful when making decisions regarding the intensity of treatment.
Collapse
Affiliation(s)
- S E Giannasi
- Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - M S Venuti
- Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.
| | - A D Midley
- Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - N Roux
- Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - C Kecskes
- Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - E San Román
- Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| |
Collapse
|
9
|
Warmerdam M, Stolwijk F, Boogert A, Sharma M, Tetteroo L, Lucke J, Mooijaart S, Ansems A, Esteve Cuevas L, Rijpsma D, de Groot B. Initial disease severity and quality of care of emergency department sepsis patients who are older or younger than 70 years of age. PLoS One 2017; 12:e0185214. [PMID: 28945774 PMCID: PMC5612649 DOI: 10.1371/journal.pone.0185214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 09/10/2017] [Indexed: 12/05/2022] Open
Abstract
Objective Due to atypical symptom presentation older patients are more prone to delayed sepsis recognition. We investigated whether initial disease severity before emergency department (ED) treatment (including treatable acute organ dysfunction), quality of ED sepsis care and the impact on mortality was different between patients older and younger than 70 years. If differences exist, improvements are needed for ED management of older patients at risk for sepsis. Methods In this observational multicenter study, ED patients who were hospitalized with a suspected infection were stratified by age <70 and ≥70 years. The presence of treatable and potentially reversible acute organ dysfunction was measured by the RO components of the Predisposition, Infection, Response and Organ dysfunction (PIRO) score, reflecting acute sepsis-related organ dysfunction developed before ED presentation. Quality of care, as assessed by the full compliance with nine quality performance measures and the standardized mortality ratio (SMR: observed/expected in-hospital mortality), was compared between older and younger patients. Results The RO-components of the PIRO score were 8 (interquartile range; 4–9) in the 833 older patients, twice as high as the 4 (2–8; P<0.001) in the 1537 younger patients. However, full compliance with all nine quality performance measures was achieved in 34.2 (31.0–37.4)% of the older patients, not higher than the 33.0 (30.7–35.4)% in younger patients (P = 0.640). In-hospital mortality was 9.2% (95%-CI, 7.3–11.2) in patients ≥70, twice as high as the 4.6% (3.6–5.6) in patients <70 years, resulting in an SMR (in study period) of ~0.7 in both groups (P>0.05). Conclusion Older sepsis patients are sicker at ED presentation but are not treated more expediently or reliably despite their extra acuity The presence of twice as much treatable acute organ dysfunction before ED treatment suggests that acute organ dysfunction is recognized relatively late by general practitioners or patients in the out of hospital setting.
Collapse
Affiliation(s)
- Mats Warmerdam
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
- * E-mail:
| | - Frank Stolwijk
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Anjelica Boogert
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Meera Sharma
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Lisa Tetteroo
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Jacinta Lucke
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| | - Simon Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Centre, Leiden, Zuid-Holland, The Netherlands & Institute for Evidence-based Medicine in Old Age | IEMO, Leiden, The Netherlands
| | - Annemieke Ansems
- Emergency Department, Albert Schweitzer Ziekenhuis, Dordrecht, Zuid-Holland, the Netherlands
| | - Laura Esteve Cuevas
- Emergency Department, Albert Schweitzer Ziekenhuis, Dordrecht, Zuid-Holland, the Netherlands
| | - Douwe Rijpsma
- Emergency Department, Rijnstate Ziekenhuis, Arnhem, Gelderland, the Netherlands
| | - Bas de Groot
- Emergency Department, Leiden University Medical Centre, Leiden, Zuid-Holland, the Netherlands
| |
Collapse
|
10
|
Ruiz LA, España PP, Gómez A, Bilbao A, Jaca C, Arámburu A, Capelastegui A, Restrepo MI, Zalacain R. Age-related differences in management and outcomes in hospitalized healthy and well-functioning bacteremic pneumococcal pneumonia patients: a cohort study. BMC Geriatr 2017. [PMID: 28633626 PMCID: PMC5477680 DOI: 10.1186/s12877-017-0518-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background Limited data are available regarding fit and healthy patients with pneumonia at different ages. We evaluated the association of age with clinical presentation, serotype and outcomes among healthy and well-functioning patients hospitalized for bacteremic pneumococcal community–acquired pneumonia. Methods We performed a prospective cohort study of consecutive healthy and well-functioning patients hospitalized for this type of pneumonia. Patients were stratified into younger (18 to 64 years) and older (≥65 years) groups. Results During the study period, 399 consecutive patients were hospitalized with bacteremic pneumococcal pneumonia. We included 203 (50.8%) patients who were healthy and well-functioning patients, of whom 71 (35%) were classified as older. No differences were found in antibiotic treatment, treatment failure rate, antibiotic resistance, or serotype, except for serotype 7F that was less common in older patients. In the adjusted multivariate analysis, the older patients had higher 30-day mortality (OR 6.83; 95% CI 1.22–38.22; P = 0.028), but were less likely to be admitted to the ICU (OR 0.14; 95% CI 0.05–0.39; P < 0.001) and had shorter hospital stays (OR 0.71; 95% CI 0.54–0.94; P = 0.017). Conclusions Healthy and well-functioning older patients have higher mortality than younger patients, but nevertheless, ICU admission was less likely and hospital stays were shorter. These results suggest that the aging process is a determinant of mortality, beyond the functional status of patients with bacteremic pneumococcal pneumonia.
Collapse
Affiliation(s)
- Luis A Ruiz
- Pneumology Service, Hospital Universitario Cruces, E-48903, Barakaldo, Bizkaia, Spain.
| | - Pedro P España
- Pneumology Service, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain
| | - Ainhoa Gómez
- Pneumology Service, Hospital Universitario Cruces, E-48903, Barakaldo, Bizkaia, Spain
| | - Amaia Bilbao
- Research Unit, Hospital Universitario Basurto - Research Network on Health Services for Chronic Diseases (REDISSEC), Bilbao, Bizkaia, Spain
| | - Carmen Jaca
- Pneumology Service, Hospital Universitario Cruces, E-48903, Barakaldo, Bizkaia, Spain
| | - Amaia Arámburu
- Pneumology Service, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain
| | | | - Marcos I Restrepo
- Division Pulmonary/Critical Care Medicine, South Texas Veterans Health Care System and University of Texas health Science Center, San Antonio, TX, USA
| | - Rafael Zalacain
- Pneumology Service, Hospital Universitario Cruces, E-48903, Barakaldo, Bizkaia, Spain
| |
Collapse
|
11
|
Ferretti-Rebustini REDL, Nogueira LDS, Silva RDCGE, Poveda VDB, Machado SP, Oliveira EMD, Andolhe R, Padilha KG. Aging as a predictor of nursing workload in Intensive Care Unit: results from a Brazilian Sample. Rev Esc Enferm USP 2017; 51:e03216. [PMID: 28380163 DOI: 10.1590/s1980-220x2016237503216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 01/06/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Verify if aging is an independent predictor of NW in ICU, according to age groups, and its predictive value as a determinant of NW in ICU. METHODS Study was conducted from 2012 to 2016. A convenience sample composed by patients (age ≥ 18) admitted to nine ICU belonging to a Brazilian hospital, was analyzed. Age was assumed as an independent variable and NW (measured by the Nursing Activities Score - NAS) as dependent. Linear regression model and ROC curve were used for the analysis. RESULTS 890 participants (361 older people), mostly males (58.1%). The mean NAS score was higher among older participants in comparison to adults (p=0.004) but not within categories of aging (p=0.697). Age was responsible for 0.6% of NAS score. Each year of age increases NAS score in 0.081 points (p=0.015). However, age was not a good predictor of NAS score (AUC = 0.394; p=0.320). CONCLUSION The care of older people in ICU is associated with an increase in NW, compared to adults. Aging can be considered an associated factor but not a good predictor of NW in ICU. OBJETIVO Verificar si el envejecimiento es un predictor independiente de la Carga de Trabajo de Enfermería (CTE) en la Unidad de Cuidados Intensivos (UCI), según grupos etarios y su valor predictivo como determinante de la CTE en la UCI. MÉTODOS Se analizó una muestra de conveniencia compuesta por pacientes (edad ≥ 18) ingresados en nueve UCI pertenecientes a un hospital brasileño. La edad se asumió como variable independiente y como variable dependiente la carga de trabajo de enfermería -medida por el sistema Nursing Activities Score (NAS) de puntuación de actividades de enfermería. Para el análisis, se utilizaron el modelo de regresión lineal y la curva ROC. RESULTADOS 890 participantes (361 adultos mayores), en su mayoría varones (58,1%). La puntuación NAS promedio fue mayor entre los participantes adultos mayores en comparación con los adultos (p=0,004), pero no en las categorías de envejecimiento (p=0,697). La edad fue responsable del 0,6% de la puntuación NAS. Cada año de edad aumenta la puntuación NAS en 0,081 puntos (p=0,015). Sin embargo, la edad no resultó un buen predictor de la puntuación NAS (AbC=0,394; p=0,320). CONCLUSIÓN El cuidado de los adultos mayores en UCI se asocia con un aumento de la CTE en comparación con los adultos. El envejecimiento puede considerarse un factor asociado, pero no un buen predictor de la CTE en UCI.
Collapse
Affiliation(s)
| | - Lilia de Souza Nogueira
- Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem Médico-Cirúrgica, São Paulo, SP, Brazil
| | - Rita de Cassia Gengo E Silva
- Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem Médico-Cirúrgica, São Paulo, SP, Brazil
| | - Vanessa de Brito Poveda
- Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem Médico-Cirúrgica, São Paulo, SP, Brazil
| | - Selma Pinheiro Machado
- Universidade de São Paulo, Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem na Saúde do Adulto, São Paulo, SP, Brazil
| | - Elaine Machado de Oliveira
- Universidade de São Paulo, Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem na Saúde do Adulto, São Paulo, SP, Brazil
| | - Rafaela Andolhe
- Universidade Federal de Santa Maria, Departamento de Enfermagem, Santa Maria, RS, Brazil
| | - Katia Grillo Padilha
- Universidade de São Paulo, Escola de Enfermagem, Departamento de Enfermagem Médico-Cirúrgica, São Paulo, SP, Brazil
| |
Collapse
|