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Levin MA, Kia A, Timsina P, Cheng FY, Nguyen KAN, Kohli-Seth R, Lin HM, Ouyang Y, Freeman R, Reich DL. Real-Time Machine Learning Alerts to Prevent Escalation of Care: A Nonrandomized Clustered Pragmatic Clinical Trial. Crit Care Med 2024; 52:1007-1020. [PMID: 38380992 DOI: 10.1097/ccm.0000000000006243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
OBJECTIVES Machine learning algorithms can outperform older methods in predicting clinical deterioration, but rigorous prospective data on their real-world efficacy are limited. We hypothesized that real-time machine learning generated alerts sent directly to front-line providers would reduce escalations. DESIGN Single-center prospective pragmatic nonrandomized clustered clinical trial. SETTING Academic tertiary care medical center. PATIENTS Adult patients admitted to four medical-surgical units. Assignment to intervention or control arms was determined by initial unit admission. INTERVENTIONS Real-time alerts stratified according to predicted likelihood of deterioration sent either to the primary team or directly to the rapid response team (RRT). Clinical care and interventions were at the providers' discretion. For the control units, alerts were generated but not sent, and standard RRT activation criteria were used. MEASUREMENTS AND MAIN RESULTS The primary outcome was the rate of escalation per 1000 patient bed days. Secondary outcomes included the frequency of orders for fluids, medications, and diagnostic tests, and combined in-hospital and 30-day mortality. Propensity score modeling with stabilized inverse probability of treatment weight (IPTW) was used to account for differences between groups. Data from 2740 patients enrolled between July 2019 and March 2020 were analyzed (1488 intervention, 1252 control). Average age was 66.3 years and 1428 participants (52%) were female. The rate of escalation was 12.3 vs. 11.3 per 1000 patient bed days (difference, 1.0; 95% CI, -2.8 to 4.7) and IPTW adjusted incidence rate ratio 1.43 (95% CI, 1.16-1.78; p < 0.001). Patients in the intervention group were more likely to receive cardiovascular medication orders (16.1% vs. 11.3%; 4.7%; 95% CI, 2.1-7.4%) and IPTW adjusted relative risk (RR) (1.74; 95% CI, 1.39-2.18; p < 0.001). Combined in-hospital and 30-day-mortality was lower in the intervention group (7% vs. 9.3%; -2.4%; 95% CI, -4.5% to -0.2%) and IPTW adjusted RR (0.76; 95% CI, 0.58-0.99; p = 0.045). CONCLUSIONS Real-time machine learning alerts do not reduce the rate of escalation but may reduce mortality.
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Affiliation(s)
- Matthew A Levin
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
- Windreich Department of Artificial Intelligence and Human Health, Icahn School of Medicine at Mount Sinai, New York, NY
- Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Anesthesiology and Yale Center for Analytical Sciences, Yale School of Medicine, New Haven, CT
| | - Arash Kia
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Prem Timsina
- Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Fu-Yuan Cheng
- Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kim-Anh-Nhi Nguyen
- Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Roopa Kohli-Seth
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hung-Mo Lin
- Department of Anesthesiology and Yale Center for Analytical Sciences, Yale School of Medicine, New Haven, CT
| | - Yuxia Ouyang
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert Freeman
- Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David L Reich
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Winters BD. Rapid Response Systems. Crit Care Clin 2024; 40:583-598. [PMID: 38796229 DOI: 10.1016/j.ccc.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
The hospital rapid response system (RRS) is a patient safety and quality intervention that responds quickly to clinical deteriorations on general wards with the goal of preventing cardiopulmonary arrests, reducing hospital mortality, and facilitating triage and level of care escalations. The RRS is one of the first organized, and systematic, elements of the "ICU without walls" model. RRSs have been shown to be effective in preventing deterioration to cardiopulmonary arrest on general hospital wards and reducing total and unexpected hospital mortality. Recent studies have demonstrated that this benefit can be enhanced through targeted improvements and modifications of existing RRSs.
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Affiliation(s)
- Bradford D Winters
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 9127 Zayed 1800 Orealns Street, Baltimore, MD 21287, USA.
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3
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Wan YKJ, Wright MC, McFarland MM, Dishman D, Nies MA, Rush A, Madaras-Kelly K, Jeppesen A, Del Fiol G. Information displays for automated surveillance algorithms of in-hospital patient deterioration: a scoping review. J Am Med Inform Assoc 2023; 31:256-273. [PMID: 37847664 PMCID: PMC10746326 DOI: 10.1093/jamia/ocad203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/12/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVE Surveillance algorithms that predict patient decompensation are increasingly integrated with clinical workflows to help identify patients at risk of in-hospital deterioration. This scoping review aimed to identify the design features of the information displays, the types of algorithm that drive the display, and the effect of these displays on process and patient outcomes. MATERIALS AND METHODS The scoping review followed Arksey and O'Malley's framework. Five databases were searched with dates between January 1, 2009 and January 26, 2022. Inclusion criteria were: participants-clinicians in inpatient settings; concepts-intervention as deterioration information displays that leveraged automated AI algorithms; comparison as usual care or alternative displays; outcomes as clinical, workflow process, and usability outcomes; and context as simulated or real-world in-hospital settings in any country. Screening, full-text review, and data extraction were reviewed independently by 2 researchers in each step. Display categories were identified inductively through consensus. RESULTS Of 14 575 articles, 64 were included in the review, describing 61 unique displays. Forty-one displays were designed for specific deteriorations (eg, sepsis), 24 provided simple alerts (ie, text-based prompts without relevant patient data), 48 leveraged well-accepted score-based algorithms, and 47 included nurses as the target users. Only 1 out of the 10 randomized controlled trials reported a significant effect on the primary outcome. CONCLUSIONS Despite significant advancements in surveillance algorithms, most information displays continue to leverage well-understood, well-accepted score-based algorithms. Users' trust, algorithmic transparency, and workflow integration are significant hurdles to adopting new algorithms into effective decision support tools.
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Affiliation(s)
- Yik-Ki Jacob Wan
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT 84108, United States
| | - Melanie C Wright
- College of Pharmacy, Idaho State University, Meridian, ID 83642, United States
| | - Mary M McFarland
- Eccles Health Sciences Library, University of Utah, Salt Lake City, UT 84112, United States
| | - Deniz Dishman
- Cizik School of Nursing Department of Research, University of Texas Health Science Center at Houston, Houston, TX 77030, United States
| | - Mary A Nies
- College of Health, Idaho State University, Pocatello, ID 83209, United States
| | - Adriana Rush
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT 84108, United States
| | - Karl Madaras-Kelly
- College of Pharmacy, Idaho State University, Meridian, ID 83642, United States
| | - Amanda Jeppesen
- College of Pharmacy, Idaho State University, Meridian, ID 83642, United States
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT 84108, United States
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Lee B, Leng J, Kerbel R. Using a Clinical Triggers System to Improve Early Recognition of Clinical Changes. CLIN NURSE SPEC 2023; 37:228-236. [PMID: 37595197 DOI: 10.1097/nur.0000000000000769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
PURPOSE A medical-surgical telemetry unit implemented a clinical triggers system for early recognition of clinical deterioration and bedside management between nurses and providers. The goal was to decrease cardiopulmonary arrest events. DESCRIPTION OF THE PROJECT A clinical triggers system was developed to help nurses to identify clinical markers early and advocate for prompt bedside assessment and interventions. When clinical triggers were identified, the nurse notified the provider, who performed a bedside assessment within 15 minutes. If the provider did not respond promptly, the rapid response team was activated. OUTCOMES Before intervention, the unit experienced 14 cardiopulmonary arrest events (rate of 1.37 per 1000 patient days). Incidences decreased annually to 5, 4, and 3 events (rates of 0.49, 0.39, and 0.3 per 1000 patient days) during the 3-year implementation period. CONCLUSIONS The clinical triggers system was successful in achieving the project objective of decreasing unit cardiopulmonary arrest events through early recognition and response to patient deterioration during the implementation period. The clinical nurse specialist helped nurses to use the clinical triggers system to detect and respond to clinical changes. Nurses were empowered to address concerns and promote patient safety.
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Affiliation(s)
- Betty Lee
- Author Affiliations: Clinical Nurse Specialist (Ms Lee) and Clinical Nurse (Ms Leng), UCLA Health; and Associate Professor of Medicine (Dr Kerbel), David Geffen School of Medicine, UCLA, Santa Monica, California
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Holland M, Kellett J. The United Kingdom's National Early Warning Score: should everyone use it? A narrative review. Intern Emerg Med 2023; 18:573-583. [PMID: 36602553 PMCID: PMC9813902 DOI: 10.1007/s11739-022-03189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/24/2022] [Indexed: 01/06/2023]
Abstract
This review critiques the benefits and drawbacks of the United Kingdom's National Early Warning Score (NEWS). Potential developments for the future are considered, as well as the role for NEWS in an emergency department (ED). The ability of NEWS to predict death within 24 h has been well validated in multiple clinical settings. It provides a common language for the assessment of clinical severity and can be used to trigger clinical interventions. However, it should not be used as the only metric for risk stratification as its ability to predict mortality beyond 24 h is not reliable and greatly influenced by other factors. The main drawbacks of NEWS are that measuring it requires trained professionals, it is time consuming and prone to calculation error. NEWS is recommended for use in acute UK hospitals, where it is linked to an escalation policy that reflects postgraduate experience; patients with lower NEWS are first assessed by a junior clinician and those with higher scores by more senior staff. This policy was based on expert opinion that did not consider workload implications. Nevertheless, its implementation has been shown to improve the efficient recording of vital signs. How and who should respond to different NEWS levels is uncertain and may vary according to the clinical setting and resources available. In the ED, simple triage scores which are quicker and easier to use may be more appropriate determinants of acuity. However, any alternative to NEWS should be easier and cheaper to use and provide evidence of outcome improvement.
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Affiliation(s)
- Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, A676 Deane Road, Bolton, BL3 5AB UK
| | - John Kellett
- Department of Emergency Medicine, University Hospital, Odense, Denmark
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Tavella E. Strategizing in pluralistic organizations: extending theoretical frames to include disrupted contexts. INTERNATIONAL STUDIES OF MANAGEMENT & ORGANIZATION 2022. [DOI: 10.1080/00208825.2022.2131228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Elena Tavella
- OMNES Education, International University of Monaco, Monaco, France
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Gottesman D, McIsaac DI. Frailty and emergency surgery: identification and evidence-based care for vulnerable older adults. Anaesthesia 2022; 77:1430-1438. [PMID: 36089855 DOI: 10.1111/anae.15860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2022] [Indexed: 11/30/2022]
Abstract
Frailty is a multidimensional state related to accumulation of age- and disease-related deficits across multiple domains. Older people represent the fastest growing segment of the peri-operative population, and 25-50% of older surgical patients live with frailty. When frailty is present before surgery, adjusted rates of morbidity and mortality increase at least two-fold; the odds of delirium and loss of independence are increased more than four- and five-fold, respectively. Care of the older person with frailty presenting for emergency surgery requires individualised and evidence-based care given the high-risk and complex nature of their presentations. Before surgery, frailty should be assessed using a multidimensional frailty instrument (most likely the Clinical Frailty Scale), and all members of the peri-operative team should be aware of each patient's frailty status. When frailty is present, pre-operative care should focus on documenting and communicating individualised risk, considering advanced care directives and engaging shared decision-making when feasible. Shared multidisciplinary care should be initiated. Peri-operatively, analgesia that avoids polypharmacy should be provided, along with delirium prevention strategies and consideration of postoperative care in a monitored environment. After the acute surgical episode, transition out of hospital requires that adequate support be in place, along with clear discharge instructions, and review of new and existing prescription medications. Advanced care directives should be reviewed or initiated in case of readmission. Overall, substantial knowledge gaps about the optimal peri-operative care of older people with frailty must be addressed through robust, patient-oriented research.
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Affiliation(s)
- D Gottesman
- Departments of Anesthesiology and Pain Medicine, University of Ottawa and Ottawa Hospita, Ottawa, ON, Canada
| | - D I McIsaac
- Departments of Anesthesiology and Pain Medicine, University of Ottawa and Ottawa Hospital, School of Epidemiology and Public Health, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Doty D, Jay K. Effects of a level-of-care tool on admission placement and rapid response use. Nursing 2022; 52:49-52. [PMID: 36006753 DOI: 10.1097/01.nurse.0000854024.20111.7e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Nurses promote performance improvement efforts that advance the practice of nursing and enhance outcomes. This special section highlights three successful performance improvement initiatives that showcase the value of these efforts.
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Affiliation(s)
- Diane Doty
- At Indianapolis Roudebush VA Medical Center, Diane Doty is a critical care nurse specialist and Katlin Jay is a critical care assistant unity manager
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Schilling S, Armaou M, Morrison Z, Carding P, Bricknell M, Connelly V. Understanding teamwork in rapidly deployed interprofessional teams in intensive and acute care: A systematic review of reviews. PLoS One 2022; 17:e0272942. [PMID: 35980893 PMCID: PMC9387792 DOI: 10.1371/journal.pone.0272942] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/31/2022] [Indexed: 12/04/2022] Open
Abstract
The rapid increase of acute and intensive care capacities in hospitals needed during the response to COVID-19 created an urgent demand for skilled healthcare staff across the globe. To upscale capacity, many hospitals chose to increase their teams in these departments with rapidly re-deployed inter-professional healthcare personnel, many of whom had no prior experience of working in a high-risk environment and were neither prepared nor trained for work on such wards. This systematic review of reviews examines the current evidence base for successful teamwork in rapidly deployed interprofessional teams in intensive and acute care settings, by assessing systematic reviews of empirical studies to inform future deployments and support of rapidly formed clinical teams. This study identified 18 systematic reviews for further analysis. Utilising an integrative narrative synthesis process supported by thematic coding and graphical network analysis, 13 themes were found to dominate the literature on teams and teamwork in inter-professional and inter-disciplinary teams. This approach was chosen to make the selection process more transparent and enable the thematic clusters in the reviewed papers to be presented visually and codifying four factors that structure the literature on inter-professional teams (i.e., team-internal procedures and dynamics, communicative processes, organisational and team extrinsic influences on teams, and lastly patient and staff outcomes). Practically, the findings suggest that managers and team leaders in fluid and ad-hoc inter-professional healthcare teams in an intensive care environment need to pay attention to reducing pre-existing occupational identities and power-dynamics by emphasizing skill mix, establishing combined workspaces and break areas, clarifying roles and responsibilities, facilitating formal information exchange and developing informal opportunities for communication. The results may guide the further analysis of factors that affect the performance of inter-professional teams in emergency and crisis deployment.
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Affiliation(s)
- Stefan Schilling
- Department of Psychology, Health & Professional Development, Oxford Brookes University, Oxford, United Kingdom
- School of Security Studies, King’s College London, London, United Kingdom
- * E-mail:
| | - Maria Armaou
- Department of Psychology, Health & Professional Development, Oxford Brookes University, Oxford, United Kingdom
- School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Zoe Morrison
- Aberdeen Business School, Robert Gordon University, Aberdeen, United Kingdom
| | - Paul Carding
- Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford, United Kingdom
| | - Martin Bricknell
- School of Security Studies, King’s College London, London, United Kingdom
| | - Vincent Connelly
- Department of Psychology, Health & Professional Development, Oxford Brookes University, Oxford, United Kingdom
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Factora F, Maheshwari K, Khanna S, Chahar P, Ritchey M, O’Hara J, Mascha EJ, Mi J, Halvorson S, Turan A, Ruetzler K. Effect of a Rapid Response Team on the Incidence of In-Hospital Mortality. Anesth Analg 2022; 135:595-604. [DOI: 10.1213/ane.0000000000006005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Guan G, Lee CMY, Begg S, Crombie A, Mnatzaganian G. The use of early warning system scores in prehospital and emergency department settings to predict clinical deterioration: A systematic review and meta-analysis. PLoS One 2022; 17:e0265559. [PMID: 35298560 PMCID: PMC8929648 DOI: 10.1371/journal.pone.0265559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/03/2022] [Indexed: 12/23/2022] Open
Abstract
Background It is unclear which Early Warning System (EWS) score best predicts in-hospital deterioration of patients when applied in the Emergency Department (ED) or prehospital setting. Methods This systematic review (SR) and meta-analysis assessed the predictive abilities of five commonly used EWS scores (National Early Warning Score (NEWS) and its updated version NEWS2, Modified Early Warning Score (MEWS), Rapid Acute Physiological Score (RAPS), and Cardiac Arrest Risk Triage (CART)). Outcomes of interest included admission to intensive care unit (ICU), and 3-to-30-day mortality following hospital admission. Using DerSimonian and Laird random-effects models, pooled estimates were calculated according to the EWS score cut-off points, outcomes, and study setting. Risk of bias was evaluated using the Newcastle-Ottawa scale. Meta-regressions investigated between-study heterogeneity. Funnel plots tested for publication bias. The SR is registered in PROSPERO (CRD42020191254). Results Overall, 11,565 articles were identified, of which 20 were included. In the ED setting, MEWS, and NEWS at cut-off points of 3, 4, or 6 had similar pooled diagnostic odds ratios (DOR) to predict 30-day mortality, ranging from 4.05 (95% Confidence Interval (CI) 2.35–6.99) to 6.48 (95% CI 1.83–22.89), p = 0.757. MEWS at a cut-off point ≥3 had a similar DOR when predicting ICU admission (5.54 (95% CI 2.02–15.21)). MEWS ≥5 and NEWS ≥7 had DORs of 3.05 (95% CI 2.00–4.65) and 4.74 (95% CI 4.08–5.50), respectively, when predicting 30-day mortality in patients presenting with sepsis in the ED. In the prehospital setting, the EWS scores significantly predicted 3-day mortality but failed to predict 30-day mortality. Conclusion EWS scores’ predictability of clinical deterioration is improved when the score is applied to patients treated in the hospital setting. However, the high thresholds used and the failure of the scores to predict 30-day mortality make them less suited for use in the prehospital setting.
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Affiliation(s)
- Gigi Guan
- Rural Department of Community Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
- Department of Rural Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Shepparton, Australia
- * E-mail:
| | - Crystal Man Ying Lee
- School of Population Health, Curtin University, Perth, Western Australia, Australia
- School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Stephen Begg
- Violet Vines Marshman Centre for Rural Health Research, La Trobe University, Bendigo, Victoria, Australia
| | - Angela Crombie
- Research & Innovation, Bendigo Health, Bendigo, Victoria, Australia
| | - George Mnatzaganian
- Rural Department of Community Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
- The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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Føns‐Sønderskov MB, Subbe C, Kodal AM, Bunkenborg G, Bestle MH. Rapid response teams-how and who? A protocol for a randomised clinical trial evaluating the composition of the efferent limb of the rapid response system. Acta Anaesthesiol Scand 2022; 66:401-407. [PMID: 34907530 DOI: 10.1111/aas.14017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Many patients experiencing deterioration have documented deviation of vital signs prior to the deterioration event. Increasing focus on these patients led to the rapid response systems and their configuration with afferent and efferent limbs. The two most prevalent team constellations in the efferent limb are the medical emergency team (MET), usually led by a doctor, and the critical care outreach team (CCOT), usually led by a nurse. The two constellations have not previously been examined in a comparative clinical trial. METHODS This is a single centre non-inferiority randomised controlled trial of MET vs CCOT. All patients will be randomised at the time of the call. The intervention group will be the critical care outreach team. The primary outcome is mortality at 30 days and the occurrence of serious adverse events. All patients will be followed for 90 days. We aim to detect or reject a change of 7% in mortality whilst accepting a type I error of 5 and type II error of 20, using a sample size of maximum of 2000 individual patients. DISCUSSION There is evidence supporting a benefit for the patient when using rapid response systems; however, earlier randomised studies are marked by cross-contamination and selection bias. Previous studies have primarily examined the effect of RRS on hospital cardiac arrests (IHCA) and mortality. Our study will be examining the effect on intensive care unit admissions as well as the ICHA and mortality. CONCLUSION This study may highlight potential benefits of specific configurations of rapid response systems and their impact on safety outcomes.
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Affiliation(s)
- Morten B. Føns‐Sønderskov
- Department of Anesthesia and Intensive Care Copenhagen University Hospital ‐ North Zealand Hillerød Denmark
| | - Chris Subbe
- School of Medical Sciences Bangor University Bangor Wales England
| | - Anne Marie Kodal
- Department of Anesthesia and Intensive Care Copenhagen University Hospital ‐ North Zealand Hillerød Denmark
| | | | - Morten H. Bestle
- Department of Anesthesia and Intensive Care Copenhagen University Hospital ‐ North Zealand Hillerød Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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Pankhurst T, Sapey E, Gyves H, Evison F, Gallier S, Gkoutos G, Ball S. Evaluation of NEWS2 response thresholds in a retrospective observational study from a UK acute hospital. BMJ Open 2022; 12:e054027. [PMID: 35135770 PMCID: PMC8830252 DOI: 10.1136/bmjopen-2021-054027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Use of National Early Warning Score 2 (NEWS2) has been mandated in adults admitted to acute hospitals in England. Urgent clinical review is recommended at NEWS2 ≥5. This policy is recognised as requiring ongoing evaluation. We assessed NEWS2 acquisition, alerting at key thresholds and patient outcomes, to understand how response recommendations would affect clinical resource allocation. SETTING Adult acute hospital in England. DESIGN Retrospective observational cohort study. PARTICIPANTS 100 362 consecutive admissions between November 2018 and July 2019. OUTCOME Death or admission to intensive care unit within 24 hours of a score. METHODS NEWS2 were assembled as single scores from consecutive 24-hour time frames, (the first NEWS2 termed 'Index-NEWS2'), or as all scores from the admission (termed All-NEWS2). Scores were excluded when a patient was in intensive care, in the presence of a decision not to attempt cardiopulmonary resuscitation, or on day 1 of elective admission. RESULTS A mean of 4.5 NEWS2 were acquired per patient per day. The outcome rate following an Index-NEWS2 was 0.22/100 patient-days. The sensitivity of outcome prediction at Index-NEWS2 ≥5=0.46, and number needed to evaluate (NNE)=52. At this threshold, a mean of 37.6 alerts/100 patient-days would be generated, occurring in 12.3% of patients on any single day. Threshold changes to increase sensitivity by 0.1, would result in a twofold increase in alert rate and 1.5-fold increase in NNE. Overall, NEWS2 classification performance was significantly worse on Index-scores than All-scores (c-statistic=0.78 vs 0.85; p<0.001). CONCLUSIONS The combination of low event-rate, high alert-rate and low sensitivity, in patients for cardiopulmonary resuscitation, means that at current NEWS2 thresholds, resource demand would be sufficient to meaningfully compete with other pathways to clinical evaluation. In analyses that epitomise in-patient screening, NEWS2 performance suggests a need for re-evaluation of current response recommendations in this population.
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Affiliation(s)
- Tanya Pankhurst
- Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- PIONEER Hub, University of Birmingham, Birmingham, UK
| | - Helen Gyves
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Felicity Evison
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Suzy Gallier
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- PIONEER Technical Director, University of Birmingham, Birmingham, UK
| | | | - Simon Ball
- Better Care, Health Data Research, London, UK
- Chief Medical Officer, University Hospitals Birmingham NHS Founation Trust, Birmingham, UK
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Jerng JS, Chen LC, Chen SY, Kuo LC, Tsan CY, Hsieh PY, Chen CM, Chuang PY, Huang HF, Huang SF. Effect of Implementing Decision Support to Activate a Rapid Response System by Automated Screening of Verified Vital Sign Data: A Retrospective Database Study. Resuscitation 2022; 173:23-30. [DOI: 10.1016/j.resuscitation.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/23/2022] [Accepted: 02/04/2022] [Indexed: 11/16/2022]
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Wan YKJ, Del Fiol G, McFarland MM, Wright MC. User interface approaches implemented with automated patient deterioration surveillance tools: protocol for a scoping review. BMJ Open 2022; 12:e055525. [PMID: 35027423 PMCID: PMC8762135 DOI: 10.1136/bmjopen-2021-055525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Early identification of patients who may suffer from unexpected adverse events (eg, sepsis, sudden cardiac arrest) gives bedside staff valuable lead time to care for these patients appropriately. Consequently, many machine learning algorithms have been developed to predict adverse events. However, little research focuses on how these systems are implemented and how system design impacts clinicians' decisions or patient outcomes. This protocol outlines the steps to review the designs of these tools. METHODS AND ANALYSIS We will use scoping review methods to explore how tools that leverage machine learning algorithms in predicting adverse events are designed to integrate into clinical practice. We will explore the types of user interfaces deployed, what information is displayed, and how clinical workflows are supported. Electronic sources include Medline, Embase, CINAHL Complete, Cochrane Library (including CENTRAL), and IEEE Xplore from 1 January 2009 to present. We will only review primary research articles that report findings from the implementation of patient deterioration surveillance tools for hospital clinicians. The articles must also include a description of the tool's user interface. Since our primary focus is on how the user interacts with automated tools driven by machine learning algorithms, electronic tools that do not extract data from clinical data documentation or recording systems such as an EHR or patient monitor, or otherwise require manual entry, will be excluded. Similarly, tools that do not synthesise information from more than one data variable will also be excluded. This review will be limited to English-language articles. Two reviewers will review the articles and extract the data. Findings from both researchers will be compared with minimise bias. The results will be quantified, synthesised and presented using appropriate formats. ETHICS AND DISSEMINATION Ethics review is not required for this scoping review. Findings will be disseminated through peer-reviewed publications.
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Affiliation(s)
- Yik-Ki Jacob Wan
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Mary M McFarland
- Eccles Health Sciences Library, University of Utah, Salt Lake City, Utah, USA
| | - Melanie C Wright
- College of Pharmacy, Idaho State University, Pocatello, Idaho, USA
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Nature and characteristics of orthopaedic medical emergency team (MET) events. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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McGaughey J, Fergusson DA, Van Bogaert P, Rose L. Early warning systems and rapid response systems for the prevention of patient deterioration on acute adult hospital wards. Cochrane Database Syst Rev 2021; 11:CD005529. [PMID: 34808700 PMCID: PMC8608437 DOI: 10.1002/14651858.cd005529.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early warning systems (EWS) and rapid response systems (RRS) have been implemented internationally in acute hospitals to facilitate early recognition, referral and response to patient deterioration as a solution to address suboptimal ward-based care. EWS and RRS facilitate healthcare decision-making using checklists and provide structure to organisational practices through governance and clinical audit. However, it is unclear whether these systems improve patient outcomes. This is the first update of a previously published (2007) Cochrane Review. OBJECTIVES To determine the effect of EWS and RRS implementation on adults who deteriorate on acute hospital wards compared to people receiving hospital care without EWS and RRS in place. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two trial registers on 28 March 2019. We subsequently ran a MEDLINE update on 15 May 2020 that identified no further studies. We checked references of included studies, conducted citation searching, and contacted experts and critical care organisations. SELECTION CRITERIA We included randomised trials, non-randomised studies, controlled before-after (CBA) studies, and interrupted time series (ITS) designs measuring our outcomes of interest following implementation of EWS and RRS in acute hospital wards compared to ward settings without EWS and RRS. DATA COLLECTION AND ANALYSIS Two review authors independently checked studies for inclusion, extracted data and assessed methodological quality using standard Cochrane and Effective Practice and Organisation of Care (EPOC) Group methods. Where possible, we standardised data to rates per 1000 admissions; and calculated risk differences and 95% confidence intervals (CI) using the Newcombe and Altman method. We reanalysed three CBA studies as ITS designs using segmented regression analysis with Newey-West autocorrelation adjusted standard errors with lag of order 1. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS We included four randomised trials (455,226 participants) and seven non-randomised studies (210,905 participants reported in three studies). All 11 studies implemented an intervention comprising an EWS and RRS conducted in high- or middle-income countries. Participants were admitted to 282 acute hospitals. We were unable to perform meta-analyses due to clinical and methodological heterogeneity across studies. Randomised trials were assessed as high risk of bias due to lack of blinding participants and personnel across all studies. Risk of bias for non-randomised studies was critical (three studies) due to high risk of confounding and unclear risk of bias due to no reporting of deviation from protocol or serious (four studies) but not critical due to use of statistical methods to control for some but not all baseline confounders. Where possible we presented original study data which reported the adjusted relative effect given these were appropriately adjusted for design and participant characteristics. We compared outcomes of randomised and non-randomised studies reported them separately to determine which studies contributed to the overall certainty of evidence. We reported findings from key comparisons. Hospital mortality Randomised trials provided low-certainty evidence that an EWS and RRS intervention may result in little or no difference in hospital mortality (4 studies, 455,226 participants; results not pooled). The evidence on hospital mortality from three non-randomised studies was of very low certainty (210,905 participants). Composite outcome (unexpected cardiac arrests, unplanned ICU admissions and death) One randomised study showed that an EWS and RRS intervention probably results in no difference in this composite outcome (adjusted odds ratio (aOR) 0.98, 95% CI 0.83 to 1.16; 364,094 participants; moderate-certainty evidence). One non-randomised study suggests that implementation of an EWS and RRS intervention may slightly reduce this composite outcome (aOR 0.85, 95% CI 0.72 to 0.99; 57,858 participants; low-certainty evidence). Unplanned ICU admissions Randomised trials provided low-certainty evidence that an EWS and RRS intervention may result in little or no difference in unplanned ICU admissions (3 studies, 452,434 participants; results not pooled). The evidence from one non-randomised study is of very low certainty (aOR 0.88, 95% CI 0.75 to 1.02; 57,858 participants). ICU readmissions No studies reported this outcome. Length of hospital stay Randomised trials provided low-certainty evidence that an EWS and RRS intervention may have little or no effect on hospital length of stay (2 studies, 21,417 participants; results not pooled). Adverse events (unexpected cardiac or respiratory arrest) Randomised trials provided low-certainty evidence that an EWS and RRS intervention may result in little or no difference in adverse events (3 studies, 452,434 participants; results not pooled). The evidence on adverse events from three non-randomised studies (210,905 participants) is very uncertain. AUTHORS' CONCLUSIONS Given the low-to-very low certainty evidence for all outcomes from non-randomised studies, we have drawn our conclusions from the randomised evidence. This evidence provides low-certainty evidence that EWS and RRS may lead to little or no difference in hospital mortality, unplanned ICU admissions, length of hospital stay or adverse events; and moderate-certainty evidence of little to no difference on composite outcome. The evidence from this review update highlights the diversity in outcome selection and poor methodological quality of most studies investigating EWS and RRS. As a result, no strong recommendations can be made regarding the effectiveness of EWS and RRS based on the evidence currently available. There is a need for development of a patient-informed core outcome set comprising clear and consistent definitions and recommendations for measurement as well as EWS and RRS interventions conforming to a standard to facilitate meaningful comparison and future meta-analyses.
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Affiliation(s)
- Jennifer McGaughey
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Peter Van Bogaert
- Nursing and Midwifery Sciences, Centre for Research and Innovation in Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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Pirret AM, Kazula LM. Removing modifications to the New Zealand Early Warning Score- does ethnicity matter? A multimethod research design. Intensive Crit Care Nurs 2021; 68:103141. [PMID: 34750043 DOI: 10.1016/j.iccn.2021.103141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/22/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous research on a modified New Zealand Early Warning Score (M-NZEWS) used in predominately medical ward patients identified removing the modifications would significantly reduce the number of M-NZEWSs triggering the medical emergency team (MET), particularly in Māori patients. AIM To firstly, explore the impact of removing the modifications from the M-NZEWS on medical and surgical ward patients' early warning score MET triggers and secondly, determine if the M-NZEWS MET triggers resulted in MET activations and if the MET activations were a result of M-NZEWS MET triggers. METHOD The study used a multimethod research design. Phase one analysed ward electronic vital sign data and phase two analysed MET and critical care outreach data from the critical care outreach data base. RESULTS Data of 353 patients and 1004 M-NZEWS MET triggers were analysed. Removing the modifications would result in 26.9% fewer patients with MET triggers, with the biggest impact on Māori. Only 45.8% of M-NZEWS MET triggers were escalated to the MET with 58.9% escalated to critical care outreach. Review of the MET activations identified only 59.2% had M-NZEWSs triggering the MET recorded in the electronic vital sign system; however the critical care outreach data base identified most of the MET activations were because of M-NZEWS MET triggers. CONCLUSION Removing the modifications would significantly reduce the number of MET triggers, particularly in Māori patients. Analysing solely electronic vital sign data may not reflect the number of medical emergency team triggers or activations.
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Affiliation(s)
- Alison M Pirret
- Critical Care Complex, Middlemore Hospital, Auckland, New Zealand; School of Nursing, Massey University, Auckland, New Zealand.
| | - Lesley M Kazula
- Critical Care Complex, Middlemore Hospital, Auckland, New Zealand
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Vergara P, Forero D, Bastidas A, Garcia JC, Blanco J, Azocar J, Bustos RH, Liebisch H. Validation of the National Early Warning Score (NEWS)-2 for adults in the emergency department in a tertiary-level clinic in Colombia: Cohort study. Medicine (Baltimore) 2021; 100:e27325. [PMID: 34622831 PMCID: PMC8500632 DOI: 10.1097/md.0000000000027325] [Citation(s) in RCA: 6] [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: 11/11/2020] [Accepted: 09/07/2021] [Indexed: 01/05/2023] Open
Abstract
The National Early Warning Score (NEWS)-2 is an early warning scale that is used in emergency departments to identify patients at risk of clinical deterioration and to help establish rapid and timely management. The objective of this study was to determine the validity and prediction of mortality using the NEWS2 scale for adults in the emergency department of a tertiary clinic in Colombia.A prospective observational study was conducted between August 2018 and June 2019 at the Universidad de La Sabana Clinic.The nursing staff in the triage classified the patients admitted to the emergency room according to Emergency Severity Index and NEWS2. Demographic data, physiological variables, admission diagnosis, mortality outcome, and comorbidities were extracted.Three thousand nine hundred eighty-six patients were included in the study. Ninety-two (2%) patients required intensive care unit management, with a mean NEWS2 score of 7. A total of 158 patients died in hospital, of which 63 were women (40%). Of these 65 patients required intensive care unit management. The receiver operating characteristic curve for NEWS2 had an area of 0.90 (CI 95%: 0.87-0.92). A classification and score equivalency analysis was performed between triage and the NEWS2 scale in terms of mortality. Of the patients classified as triage I, 32.3% died, and those who obtained a NEWS2 score greater than or equal to 10 had a mortality of 38.6%.Among our population, NEWS2 was not inferior in its area under the receiver operating characteristic curve when predicting mortality than triage, and the cutoff point for NEWS2 to predict in-hospital mortality was higher.
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Affiliation(s)
- Peter Vergara
- Evidence-based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Clínica Universidad de La Sabana, Chía, Colombia
- Clinical Pharmacology Service, Clínica Universidad de La Sabana, Colombia
| | - Daniela Forero
- Faculty of Medicine, Universidad de La Sabana, Chía, Colombia
| | - Alirio Bastidas
- Research Department, Faculty of Medicine, Universidad de La Sabana, Chía, Colombia
| | - Julio-Cesar Garcia
- Evidence-based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Clínica Universidad de La Sabana, Chía, Colombia
- Clinical Pharmacology Service, Clínica Universidad de La Sabana, Colombia
| | - Jhosep Blanco
- Evidence-based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Clínica Universidad de La Sabana, Chía, Colombia
| | - Jorge Azocar
- Faculty of Medicine, Universidad de La Sabana, Chía, Colombia
| | - Rosa-Helena Bustos
- Evidence-based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Clínica Universidad de La Sabana, Chía, Colombia
| | - Hans Liebisch
- Evidence-based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Clínica Universidad de La Sabana, Chía, Colombia
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Olsson A, Sjöberg F, Salzmann-Erikson M. Follow the protocol and kickstart the heart-Intensive care nurses' reflections on being part of rescue situations in interdisciplinary teams. Nurs Open 2021; 8:3325-3333. [PMID: 34431610 PMCID: PMC8510712 DOI: 10.1002/nop2.1050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/20/2021] [Accepted: 07/19/2021] [Indexed: 11/09/2022] Open
Abstract
Aim To describe intensive care nurses' reflections on being part of interdisciplinary emergency teams involved in in‐hospital cardiopulmonary resuscitation. Design A qualitative descriptive design. Methods: Eighteen intensive care nurses from two regions and three hospitals in Sweden were interviewed. The data were analysed with General Inductive Analysis. Results The work for intensive care nurses in the emergency team was reflected in three phases: prevention, intervention and mitigation—referred as before, during and after the CPR situation. Conclusions The findings describe the complexity of being an intensive care nurse in an interdisciplinary emergency team, which entails managing advanced care with limited and unknown resources in a non‐familiar environment. The present findings have important clinical implications concerning the value of having debriefing sessions to reflect on and to talk about obstacles to and prerequisites for performing successful resuscitation.
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Affiliation(s)
- Annakarin Olsson
- Department of Caring Sciences, Faculty of Health and Occupational Studies, University of Gävle, Gävle, Sweden
| | - Fredric Sjöberg
- Unit of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Salzmann-Erikson
- Department of Caring Sciences, Faculty of Health and Occupational Studies, University of Gävle, Gävle, Sweden
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Engebretsen S, Bogstrand ST, Jacobsen D, Rimstad R. Quality of care, resource use and patient outcome by use of emergency response team compared with standard care for critically ill medical patients in the emergency department: a retrospective single-centre cohort study from Norway. BMJ Open 2021; 11:e047264. [PMID: 34385247 PMCID: PMC8362729 DOI: 10.1136/bmjopen-2020-047264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The study aimed to investigate quality of care, resource use and patient outcome in management by an emergency response team versus standard care for critically ill medical patients in the emergency department (ED). The emergency response team was multidisciplinary and had eight members, with a registrar in internal medicine as team leader. DESIGN Register-based retrospective cohort study. SETTING Tertiary hospital in Norway. PARTICIPANTS The study included 1120 patients with National Early Warning Score 2 (NEWS2) 5-10 points from 2015 and 2016. Patients missing ≥3 NEWS2 part scores, <18 years and with orders 'Not for ICU' or 'Not for resuscitation' were excluded. OUTCOME MEASURES Quality of care: pain assessment documented, analgesics given within 20 min, complete set of vital signs documented and antibiotics within 60 min if sepsis. Resource use: >3 diagnostic interventions, critical care in the ED and ED length of stay (LOS) <180 min. Patient outcome: intensive care unit (ICU) admission, ICU LOS <66 hours, hospital LOS <194 hours and mortality. RESULTS The median age was 66 years, 53.5% were male, 44.3% were admitted to the ICU and the mortality rate was 10.6%. Altogether 691 patients received team management and 429 standard care. Team management had a positive association with 'complete set of vital signs documented' (OR 1.720, CI 1.254 to 2.360), 'analgesics given within 20 minutes' (OR 3.268, CI 1.375 to 7.767) and 'antibiotics within 60 minutes if sepsis' (OR 7.880, CI 3.322 to 18.691), but a negative association with ' pain assessment documented' (OR 0.068, CI 0.037 to 0.128). Team management was also associated with 'critical care in the ED' (OR 9.900, CI 7.127 to 13.751), 'ED LOS <180 min' (OR 2.944, CI 2.070 to 4.187), 'ICU admission' (OR 2.763, CI 1.962 to 3.891) and 'mortality' (OR 1.882, CI 1.142 to 3.102). CONCLUSIONS Team management showed positive results for quality of care and resource use. The results for later outcomes such as mortality, ICU LOS and hospital LOS were more ambiguous.
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Affiliation(s)
- Stine Engebretsen
- Emergency Department, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Dag Jacobsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Acute Medicine, Division of Medicine, Oslo University Hospital, Oslo, Norway
| | - Rune Rimstad
- Joint Medical Services, Norwegian Armed Forces, Sessvollmoen, Norway
- Department of Corporate Governance, South-Eastern Norway Regional Health Authority, Hamar, Norway
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An Exploratory Investigation into the Roles of Critical Care Response Teams in End-of-Life Care. Crit Care Res Pract 2021; 2021:4937241. [PMID: 34336279 PMCID: PMC8324371 DOI: 10.1155/2021/4937241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 04/29/2021] [Accepted: 07/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background Critical Care Response Teams (CCRTs) represent an important interface between end-of-life care (EOLC) and critical care medicine (CCM). The aim of this study was to explore the roles and interactions of CCRTs in the provision of EOLC from the perspective of CCRT members. Methods Twelve registered nurses (RNs) and four respiratory therapists (RTs) took part in focus groups, and one-on-one interviews were conducted with six critical care physicians. Thematic coding using a modified constructivist grounded theory approach was used to identify emerging themes through an iterative process involving a four-member coding team. Results Three main perspectives were identified that spoke to CCRT interactions and perceptions of EOLC encounters. CCRT members felt that they provide a unique skill set of multidisciplinary expertise in treating critically ill patients and evaluating the utility of intensive care treatments. However, despite feeling that they possessed the skills and resources to deliver quality EOLC, CCRT members were ambivalent with respect to whether EOLC was a part of their mandate. Challenges were also identified that impacted the ability of CCRTs to deliver quality EOLC. Conclusions This research aids in understanding for the first time CCRT roles in EOLC from the perspectives of individual CCRT members themselves. While CCRTs provide unique multidisciplinary expertise to evaluate the utility of intensive care treatments, opportunities exist to support CCRTs in EOLC, such as dedicated EOLC training, protocols for advance care planning, documentation, and transitions to palliative care.
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Blumenthal EA, Hooshvar N, Tancioco V, Newman R, Senderoff D, McNulty J. Implementation and Evaluation of an Electronic Maternal Early Warning Trigger Tool to Reduce Maternal Morbidity. Am J Perinatol 2021; 38:869-879. [PMID: 33368094 DOI: 10.1055/s-0040-1721715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We compare maternal morbidity and clinical care metrics before and after the electronic implementation of a maternal early warning trigger (MEWT) tool. STUDY DESIGN This is a study of maternal morbidity and clinical care within three linked hospitals comparing 1 year before and after electronic MEWT implementation. We compare severe maternal morbidity overall as well as within the subcategories of hemorrhage, hypertension, cardiopulmonary, and sepsis in addition to relevant process metrics in each category. We describe the MEWT trigger rate in addition to MEWT sensitivity and specificity for morbidity overall and by morbidity type. RESULTS The morbidity rate ratio increased from 1.6 per 100 deliveries in the pre-MEWT period to 2.06 per 100 deliveries in the post-MEWT period (incidence rate ratio = 1.28, p = 0.018); however, in cases of septic morbidity, time to appropriate antibiotics decreased (pre-MEWT: 1.87 hours [1.11-2.63] vs. post-MEWT: 0.75 hours [0.31-1.19], p = 0.036) and in cases of hypertensive morbidity, the proportion of cases treated with appropriate antihypertensive medication within 60 minutes improved (pre-MEWT: 62% vs. post-MEWT: 83%, p = 0.040). The MEWT trigger rate was 2.3%, ranging from 0.8% in the less acute centers to 2.9% in our tertiary center. The MEWT sensitivity for morbidity overall was 50%; detection of hemorrhage morbidity was lowest (30%); however, it ranged between 69% for septic morbidity, 74% for cardiopulmonary morbidity, and 82% for cases of hypertensive morbidity. CONCLUSION Overall, maternal morbidity did not decrease after implementation of the MEWT system; however, important clinical metrics such as time to antibiotics and antihypertensive care improved. We suspect increased morbidity was related to annual variation and unexpected lower morbidity in the pre-MEWT comparison year. Because MEWT sensitivity for hemorrhage was low, and because hemorrhage dominates administrative metrics of morbidity, process metrics around sepsis, hypertension, and cardiopulmonary morbidity are important to track as markers of MEWT efficacy. KEY POINTS · MEWT was not associated with a decrease in maternal morbidity.. · MEWT was associated with improvements in some clinical care metrics.. · MEWT is more sensitive in detecting septic, hypertensive, and cardiopulmonary morbidities than hemorrhage morbidity..
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Affiliation(s)
- Elizabeth A Blumenthal
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California
| | - Nina Hooshvar
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California
| | - Virginia Tancioco
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California
| | - Rachel Newman
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California
| | - Dana Senderoff
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California
| | - Jennifer McNulty
- Department of Obstetrics and Gynecology, Long Beach Memorial Miller Children's and Women's Hospital, Long Beach, California
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Pimentel MAF, Redfern OC, Malycha J, Meredith P, Prytherch D, Briggs J, Young JD, Clifton DA, Tarassenko L, Watkinson PJ. Detecting Deteriorating Patients in the Hospital: Development and Validation of a Novel Scoring System. Am J Respir Crit Care Med 2021; 204:44-52. [PMID: 33525997 PMCID: PMC8437126 DOI: 10.1164/rccm.202007-2700oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 02/01/2021] [Indexed: 12/23/2022] Open
Abstract
Rationale: Late recognition of patient deterioration in hospital is associated with worse outcomes, including higher mortality. Despite the widespread introduction of early warning score (EWS) systems and electronic health records, deterioration still goes unrecognized. Objectives: To develop and externally validate a Hospital- wide Alerting via Electronic Noticeboard (HAVEN) system to identify hospitalized patients at risk of reversible deterioration. Methods: This was a retrospective cohort study of patients 16 years of age or above admitted to four UK hospitals. The primary outcome was cardiac arrest or unplanned admission to the ICU. We used patient data (vital signs, laboratory tests, comorbidities, and frailty) from one hospital to train a machine-learning model (gradient boosting trees). We internally and externally validated the model and compared its performance with existing scoring systems (including the National EWS, laboratory-based acute physiology score, and electronic cardiac arrest risk triage score). Measurements and Main Results: We developed the HAVEN model using 230,415 patient admissions to a single hospital. We validated HAVEN on 266,295 admissions to four hospitals. HAVEN showed substantially higher discrimination (c-statistic, 0.901 [95% confidence interval, 0.898-0.903]) for the primary outcome within 24 hours of each measurement than other published scoring systems (which range from 0.700 [0.696-0.704] to 0.863 [0.860-0.865]). With a precision of 10%, HAVEN was able to identify 42% of cardiac arrests or unplanned ICU admissions with a lead time of up to 48 hours in advance, compared with 22% by the next best system. Conclusions: The HAVEN machine-learning algorithm for early identification of in-hospital deterioration significantly outperforms other published scores such as the National EWS.
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Affiliation(s)
| | - Oliver C. Redfern
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - James Malycha
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Paul Meredith
- Research and Innovation Department, Portsmouth Hospitals University National Health Service Trust, Portsmouth, United Kingdom
| | - David Prytherch
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, United Kingdom; and
| | - Jim Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, United Kingdom; and
| | - J. Duncan Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - David A. Clifton
- Institute of Biomedical Engineering, Department of Engineering Science, and
| | - Lionel Tarassenko
- Institute of Biomedical Engineering, Department of Engineering Science, and
| | - Peter J. Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Kadoorie Centre for Critical Care Research and Education, Oxford University Hospitals National Health Service Trust, Oxford, United Kingdom
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Gadhoumi K, Beltran A, Scully CG, Xiao R, Nahmias DO, Hu X. Technical considerations for evaluating clinical prediction indices: a case study for predicting code blue events with MEWS. Physiol Meas 2021; 42. [PMID: 33902012 DOI: 10.1088/1361-6579/abfbb9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/26/2021] [Indexed: 11/11/2022]
Abstract
Objective.There have been many efforts to develop tools predictive of health deterioration in hospitalized patients, but comprehensive evaluation of their predictive ability is often lacking to guide implementation in clinical practice. In this work, we propose new techniques and metrics for evaluating the performance of predictive alert algorithms and illustrate the advantage of capturing the timeliness and the clinical burden of alerts through the example of the modified early warning score (MEWS) applied to the prediction of in-hospital code blue events.Approach. Different implementations of MEWS were calculated from available physiological parameter measurements collected from the electronic health records of ICU adult patients. The performance of MEWS was evaluated using conventional and a set of non-conventional metrics and approaches that take into account the timeliness and practicality of alarms as well as the false alarm burden.Main results. MEWS calculated using the worst-case measurement (i.e. values scoring 3 points in the MEWS definition) over 2 h intervals significantly reduced the false alarm rate by over 50% (from 0.19/h to 0.08/h) while maintaining similar sensitivity levels as MEWS calculated from raw measurements (∼80%). By considering a prediction horizon of 12 h preceding a code blue event, a significant improvement in the specificity (∼60%), the precision (∼155%), and the work-up to detection ratio (∼50%) could be achieved, at the cost of a relatively marginal decrease in sensitivity (∼10%).Significance. Performance aspects pertaining to the timeliness and burden of alarms can aid in understanding the potential utility of a predictive alarm algorithm in clinical settings.
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Affiliation(s)
- Kais Gadhoumi
- School of Nursing, Duke University, Durham, NC, United States of America
| | - Alex Beltran
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States of America
| | - Christopher G Scully
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, United States of America
| | - Ran Xiao
- School of Nursing, Duke University, Durham, NC, United States of America
| | - David O Nahmias
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, United States of America
| | - Xiao Hu
- School of Nursing, Duke University, Durham, NC, United States of America
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Azimirad M, Magnusson C, Wiseman A, Selander T, Parviainen I, Turunen H. British and Finnish nurses' attitudes, practice, and knowledge on deteriorating patient in-service education: A study in two acute hospitals. Nurse Educ Pract 2021; 54:103093. [PMID: 34052539 DOI: 10.1016/j.nepr.2021.103093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 04/12/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
AIM The aim was to assess both nurses' attitudes about in-service education, and the impact had by attending in-service education on nurses' management and knowledge of deteriorating patients. BACKGROUND In-service education cannot reach its best potential outcomes without strong leadership. Nurse managers are in a position of adopting leadership styles and creating conditions for enhancing the in-service education outcomes. DESIGN We conducted a comparative cross-sectional study between British and Finnish nurses (N = 180; United Kingdom: n = 86; Finland: n = 94). METHODS A modified "Rapid Response Team Survey" was used in data collection. A sample of medical and surgical registered nurses were recruited from acute care hospitals. Self-reporting, self-reflection, and case-scenarios were used to assess nurses' attitudes, practice, and knowledge. Data were analyzed by Mann-Whitney-U and Chi-square tests. RESULTS Nurses' views on education programs were positive; however, low confidence, delays caused by hospital culture, and fear of criticism remained barriers to post education management of deteriorating patients. Nurses' self-reflection on their management of deteriorating patients indicates that 20-25% of deteriorating patients are missed. CONCLUSION Nurse managers should promote a no-blame culture, mitigate unnecessary hospital culture and routines, and facilitate in-service education focusing on identification and management of deteriorating patients, simultaneously improving nurses' confidence.
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Affiliation(s)
- Mina Azimirad
- University of Eastern Finland (UEF), Department of Nursing Science, POBox 1627, 70211 Kuopio, Finland.
| | - Carin Magnusson
- Duke of Kent Building, School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, Surrey, UK.
| | - Allison Wiseman
- College of Health & Life Sciences, Brunel University London, Uxbridge UB8 3BH, UK.
| | | | | | - Hannele Turunen
- University of Eastern Finland (UEF), Department of Nursing Science, POBox 1627, 70211 Kuopio, Finland; Kuopio University Hospital, Kuopio, Finland.
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de Ree R, Willemsen J, Te Grotenhuis G, de Ree R, Kolkert J, Peppelman M. Continuous monitoring in COVID-19 care: a retrospective study in time of crisis. JAMIA Open 2021; 4:ooab030. [PMID: 34136756 PMCID: PMC8083333 DOI: 10.1093/jamiaopen/ooab030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/11/2021] [Accepted: 04/09/2021] [Indexed: 11/13/2022] Open
Abstract
Background A new monitoring system was implemented to support nursing staff and physicians on the COVID-19 ward. This system was designed to remotely monitor vital signs, to calculate an automated Early Warning Score, and to help identify patients at risk of deterioration. Methods Hospitalized patients who tested positive for SARS-CoV-2 were connected to 2 wireless sensors measuring vital signs. Patients were divided into 2 groups based on the occurrence of adverse events during hospitalization. Heart and respiratory rate were monitored continuously and an automated EWS was calculated every 5 minutes. Data were compared between groups. Results Prior to the occurrence of adverse events, significantly higher median heart and respiration rate and significantly lower median SPO2 values were observed. Mean and median automated EWS were significantly higher in patients with an adverse event. Conclusion Continuous monitoring systems might help to detect clinical deterioration in COVID-19 patients at an earlier stage.
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Affiliation(s)
- Roy de Ree
- Department of Health Innovation, Slingeland Hospital, Doetinchem, Gelderland, The Netherlands
| | - Jorn Willemsen
- Department of Health Innovation, Slingeland Hospital, Doetinchem, Gelderland, The Netherlands
| | - Gilbert Te Grotenhuis
- Department of Health Innovation, Slingeland Hospital, Doetinchem, Gelderland, The Netherlands
| | - Rick de Ree
- Department of Health Innovation, Slingeland Hospital, Doetinchem, Gelderland, The Netherlands
| | - Joé Kolkert
- Department of Surgery, Slingeland Hospital, Doetinchem, Gelderland, The Netherlands
| | - Malou Peppelman
- Department of Health Innovation, Slingeland Hospital, Doetinchem, Gelderland, The Netherlands
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Jakobsen RK, Bonde A, Sillesen M. Assessment of post-trauma complications in eight million trauma cases over a decade in the USA. Trauma Surg Acute Care Open 2021; 6:e000667. [PMID: 33869787 PMCID: PMC8009234 DOI: 10.1136/tsaco-2020-000667] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/11/2021] [Accepted: 03/08/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Trauma is associated with a significant risk of post-trauma complications (PTCs). These include thromboembolic events, strokes, infections, and failure of organ systems (eg, kidney failure). Although care of the trauma patient has evolved during the last decade, whether this has resulted in a reduction in specific PTCs is unknown. We hypothesize that the incidence of PTCs has been decreasing during a 10-year period from 2007 to 2017. METHODS This is a descriptive study of trauma patients originating from level 1, 2, 3, and 4 trauma centers in the USA, obtained via the Trauma Quality Improvement Program (TQIP) database from 2007 to 2017. PTCs documented throughout the time frame were extracted along with demographic variables. Multiple regression modeling was used to associate admission year with PTCs, while controlling for age, gender, Glasgow Coma Scale score, and Injury Severity Score. RESULTS Data from 8 720 026 trauma patients were extracted from the TQIP database. A total of 366 768 patients experienced one or more PTCs. There was a general decrease in the incidence of PTCs during the study period, with the overall incidence dropping from 7.0% in 2007 to 2.8% in 2017. Multiple regression identified a slight decrease in incidence in all PTCs, although deep surgical site infection (SSI), deep venous thrombosis (DVT), and stroke incidences increased when controlled for confounders. DISCUSSION Overall the incidence of PTCs dropped during the 10-year study period, although deep SSI, DVT, stroke, and cardiac arrest increased during the study period. Better risk prediction tools, enabling a precision medicine approach, are warranted to identify at-risk patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Rasmus Kirial Jakobsen
- Department of Surgical Gastroenterology and Transplantation C-TX, Rigshospitalet, Kobenhavn, Denmark
- Center for Surgical Translational and Artificial Intelligence Research (CSTAR), Copenhagen, Denmark
| | - Alexander Bonde
- Department of Surgical Gastroenterology and Transplantation C-TX, Rigshospitalet, Kobenhavn, Denmark
- Center for Surgical Translational and Artificial Intelligence Research (CSTAR), Copenhagen, Denmark
| | - Martin Sillesen
- Department of Surgical Gastroenterology and Transplantation C-TX, Rigshospitalet, Kobenhavn, Denmark
- Center for Surgical Translational and Artificial Intelligence Research (CSTAR), Copenhagen, Denmark
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Low compliance to a vital sign safety protocol on general hospital wards: A retrospective cohort study. Int J Nurs Stud 2021; 115:103849. [DOI: 10.1016/j.ijnurstu.2020.103849] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 11/20/2022]
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Li Y, Guo Y, Chen D. Emergency mortality of non-trauma patients was predicted by qSOFA score. PLoS One 2021; 16:e0247577. [PMID: 33626105 PMCID: PMC7904145 DOI: 10.1371/journal.pone.0247577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 02/09/2021] [Indexed: 11/19/2022] Open
Abstract
Objective This study was aimed to evaluate the performance of quick sequential organ failure assessment (qSOFA) in predicting the emergency department (ED) mortality of non-trauma patients and to expand the application scope of qSOFA score. Methods A single, retrospective review of non-trauma patients was conducted in ED between November 1, 2016 and November 1, 2019. The qSOFA score was obtained from vital signs and Glasgow Coma Scale (GCS) score. The outcome was ED mortality. Multivariable logistic regression analysis was performed to explore the association between the qSOFA score and ED mortality. The area under the receiver operating characteristic (AUROC) curve, the best cutoff value, sensitivity and specificity were performed to ascertain the predictive value of the qSOFA score. Results 228(1.96%) of the 11621 patients were died. The qSOFA score was statistically higher in the non-survival group (P<0.001). The qSOFA score 0 subgroup was used as reference baseline, after adjusting for gender and age, adjusted OR of 1, 2 and 3 subgroups were 4.77 (95%CI 3.40 to 6.70), 18.17 (95%CI 12.49 to 26.44) and 23.63 (95%CI 9.54 to 58.52). All these three subgroups show significantly higher ED mortality compared to qSOFA 0 subgroup (P<0.001). AUROC of qSOFA score was 0.76 (95% CI 0.73 to 0.79). The best cutoff value was 0, sensitivity was 77.63% (95%CI 71.7% to 82.9%), and specificity was 67.2% (95%CI 66.3% to 68.1%). Conclusion The qSOFA score was associated with ED mortality in non-trauma patients and showed good prognostic performance. It can be used as a general tool to evaluate non-trauma patients in ED. This is just a retrospective cohort study, a prospective or a randomized study will be required.
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Affiliation(s)
- Yufang Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, China
| | - Yanxia Guo
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, China
| | - Du Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province, China
- * E-mail:
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Abstract
Objective The aim of this systematic review was to synthesize the evidence on the impact of rapid response teams (RRTs) on failure to rescue events. Methods Systematic searches were conducted using CINAHL, MEDLINE, PsychINFO, and Cochrane, for articles published from 2008 to 2018. English-language, peer-reviewed articles reporting the impact of RRTs on failure to rescue events, including hospital mortality and in-hospital cardiac arrest events, were included. For selected articles, the authors abstracted information, with the study designed to be compliant with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Results Ten articles were identified for inclusion: 3 meta-analyses, 3 systematic reviews, and 4 single studies. The systematic reviews and meta-analyses were of moderate-to-high quality, limited by the methodological quality of the included individual studies. The single studies were both observational and investigational in design. Patient outcomes included hospital mortality (8 studies), in-hospital cardiac arrests (9 studies), and intensive care unit (ICU) transfer rates (5 studies). There was variation in the composition of RRTs, and 4 studies conducted subanalyses to examine the effect of physician inclusion on patient outcomes. Conclusions There is moderate evidence linking the implementation of RRTs with decreased mortality and non-ICU cardiac arrest rates. Results linking RRT to ICU transfer rates are inconclusive and challenging to interpret. There is some evidence to support the use of physician-led teams, although evaluation of team composition was variable. Lastly, the benefits of RRTs may take a significant period after implementation to be realized, owing to the need for change in safety culture.
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Tanner J, Cornish J. Routine critical care step-down programmes: Systematic review and meta-analysis. Nurs Crit Care 2020; 26:118-127. [PMID: 33159400 DOI: 10.1111/nicc.12572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients discharged from critical care to general hospital wards are vulnerable to clinical deterioration, critical care readmission, and death. In response, routine critical care stepdown programmes (CCSDPs) have been widely developed, which involve the review of all patients on general wards following discharge from critical care by multidisciplinary Outreach teams with critical care skills. AIMS AND OBJECTIVES This review aims to answer the question: do routine CCSDPs reduce readmission and/or mortality among patients discharged from critical care? DESIGN Systematic review of quantitative studies and meta-analysis. METHODS Six databases were comprehensively searched from inception (CENTRAL, Cochrane Reviews, MEDLINE, Embase, CINAHL and web of Science), alongside grey literature and trial registers. Studies investigating the effect of routine CCSDPs delivered by Outreach nurses on readmission and/or mortality following discharge from adult critical care to general hospital wards were included. Study quality was assessed using the Cochrane ROBINS-I tool. RESULTS Eight studies met the inclusion criteria, with data from 6 studies pooled in 3 meta-analyses. Among patients exposed to routine CCSDPs, pooled data estimated a statistically nonsignificant reduction in the risk of readmission to critical care (risk ratio [RR] 0.85; 95% confidence interval [CI] 0.66-1.09; P = .19), a statistically significant increase in the risk of readmission to critical care within 72 hours (RR 1.49; 95% CI 1.05-2.12; P = .03), a statistically non-significant reduction in risk of mortality following critical care discharge (RR 0.90; 95% CI 0.75-1.07; P = .22), and no association with mortality within 14 days of discharge. CONCLUSION This review is unable to definitively conclude whether routine CCSDPs reduce critical care readmission or mortality following critical care discharge. RELEVANCE TO CLINICAL PRACTICE While the synthesized evidence does not suggest a change in policy and practice are warranted, neither does it support routine CCSDPs in the absence of high-quality evidence.
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Affiliation(s)
- John Tanner
- Clinical Response Team, Guys' & St Thomas' NHS Foundation Trust, Westminster Bridge, London, UK
| | - Jocelyn Cornish
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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Lee JR, Jung YK, Kim HJ, Koh Y, Lim CM, Hong SB, Huh JW. Derivation and validation of modified early warning score plus SpO2/FiO2 score for predicting acute deterioration of patients with hematological malignancies. Korean J Intern Med 2020; 35:1477-1488. [PMID: 32114753 PMCID: PMC7652654 DOI: 10.3904/kjim.2018.438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 06/22/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND/AIMS Scoring systems play an important role in predicting intensive care unit (ICU) admission or estimating the risk of death in critically ill patients with hematological malignancies. We evaluated the modified early warning score (MEWS) for predicting ICU admissions and in-hospital mortality among at-risk patients with hematological malignancies and developed an optimized MEWS. METHODS We retrospectively analyzed derivation cohort patients with hematological malignancies who were managed by a medical emergency team (MET) in the general ward and prospectively validated the data. We compared the traditional MEWS with the MEWS plus SpO2/FiO2 (MEWS_SF) score, which were calculated at the time of MET contact. RESULTS In the derivation cohort, the areas under the receiver-operating characteristic (AUROC) curves were 0.81 for the MEWS (95% confidence interval [CI], 0.76 to 0.87) and 0.87 for the MEWS_SF score (95% CI, 0.87 to 0.92) for predicting ICU admission. The AUROC curves were 0.70 for the MEWS (95% CI, 0.63 to 0.77) and 0.76 for the MEWS_SF score (95% CI, 0.70 to 0.83) for predicting in-hospital mortality. In the validation cohort, the AUROC curves were 0.71 for the MEWS (95% CI, 0.66 to 0.77) and 0.83 for the MEWS_SF score (95% CI, 0.78 to 0.87) for predicting ICU admission. The AUROC curves were 0.64 for the MEWS (95% CI, 0.57 to 0.70) and 0.74 for the MEWS_SF score (95% CI, 0.69 to 0.80) for predicting in-hospital mortality. CONCLUSION Compared to the traditional MEWS, the MEWS_SF score may be a useful tool that can be used in the general ward to identify deteriorating patients with hematological malignancies.
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Affiliation(s)
- Ju-Ry Lee
- Medical Emergency Team, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youn-Kyoung Jung
- Medical Emergency Team, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwa Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence to Jin Won Huh, M.D. Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3985 Fax: +82-2-3010-6968 E-mail:
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Hogan H, Hutchings A, Wulff J, Carver C, Holdsworth E, Nolan J, Welch J, Harrison D, Black N. Type of Track and Trigger system and incidence of in-hospital cardiac arrest: an observational registry-based study. BMC Health Serv Res 2020; 20:885. [PMID: 32948171 PMCID: PMC7501601 DOI: 10.1186/s12913-020-05721-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 09/08/2020] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Helen Hogan
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Room 117, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Andrew Hutchings
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Room 117, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Jerome Wulff
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Catherine Carver
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Room 117, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Elizabeth Holdsworth
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Room 117, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Jerry Nolan
- Royal United Hospital Bath NHS Trust, Combe Park, Bath, BA1 3NG, UK
| | - John Welch
- Critical Care Outreach, University College London Hospitals NHS Foundation Trust, 235 Euston Rd, Fitzrovia, London, NW1 2BU, UK
| | - David Harrison
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Nick Black
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Room 117, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Ezzati E, Mohammadi S, Karimpour H, Saman JA, Goodarzi A, Jalali A, Almasi A, Vafaei K, Kawyannejad R. Assessing the effect of arrival time of physician and cardiopulmonary resuscitation (CPR) team on the outcome of CPR. Interv Med Appl Sci 2020; 11:139-145. [PMID: 36343298 PMCID: PMC9467330 DOI: 10.1556/1646.10.2018.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 05/19/2018] [Accepted: 05/23/2018] [Indexed: 11/21/2022] Open
Abstract
Introduction Negligence of proper time and poor performance of resuscitation team can lead to more mortality and negative consequences of cardiac arrest, as well as less survival. This study was conducted with objective of determining the arrival time of physician and resuscitation team to survive the victims of cardiopulmonary arrest. Materials and methods In this prospective and descriptive-analytic study, the resuscitation performance and the arrival time of resuscitation team in 143 inpatients who had been diagnosed with witnessed cardiopulmonary arrest were examined using a researcher-made checklist. Data analysis was performed using parametric and non-parametric statistical tests and SPSS. Results Initial survival rate was 26.6%. In general, the mean time of physician’s presence after the code announcement in minutes and seconds was 02:31 ± 01:22. It was also 02:24 ± 01:15 in successful cases and 02:34 ± 01:25 in unsuccessful cases. Independent t-test did not show a significant difference between the physician’s presence time and the rate of initial successful resuscitation (p = 0.504). The time of first shock after observing ventricular fibrillation/tachycardia (in minutes and seconds) was 01:30 ± 00:47. According to independent t-test, the aforementioned time was less than the mean time (02:31 ± 01:22) of physician’s presence (p < 0.001). Conclusions In this study, the initial survival rate in comparison to other regions in the country was almost more favorable and it was similar to global norms. In this study, the starting time of resuscitation was within the acceptable range. There was no relationship between the presence of physician and the initial survival rate of patients, as well as the use of defibrillator (by physician compared to other team members) and intubation with the initial survival rate. This could indicate the adequate performance of resuscitation team in the absence of physician on the condition of having sufficient knowledge and skill.
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Affiliation(s)
- Ebrahim Ezzati
- 1 Department of Anesthesiology, School of Allied Medical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Saeed Mohammadi
- 2 Department of Anesthesiology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Hassanali Karimpour
- 2 Department of Anesthesiology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Javad Amini Saman
- 2 Department of Anesthesiology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Afshin Goodarzi
- 3 Department of Medical Emergency, School of Allied Medical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran
- 4 Department of Nursing, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Amir Jalali
- 5 Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Afshin Almasi
- 6 Department of Biostatistics and Epidemiology, School of Health Public, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Kamran Vafaei
- 7 Critical Care Nursing, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Rasool Kawyannejad
- 1 Department of Anesthesiology, School of Allied Medical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Engebretsen S, Bogstrand ST, Jacobsen D, Vitelli V, Rimstad R. NEWS2 versus a single-parameter system to identify critically ill medical patients in the emergency department. Resusc Plus 2020; 3:100020. [PMID: 34223303 PMCID: PMC8244393 DOI: 10.1016/j.resplu.2020.100020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/18/2020] [Accepted: 07/21/2020] [Indexed: 01/01/2023] Open
Abstract
AIM To test National Early Warning Score 2 (NEWS2) versus a single-parameter system to identify critically ill general medical patients in the emergency department (ED), by 1) testing NEWS2s prediction of and association with primary outcome 'mortality' (hospital or 30 day) and secondary outcomes 'intensive care unit (ICU) admission' and 'critical care in ED' and 2) comparing this for different NEWS2 cut-offs and the single-parameter system in use. METHODS Register-data on adult triage 1 and 2 patients with complete NEWS2 from 2015 and 2016 were retrieved. Prediction was assessed using area under the receiver-operating characteristic curve. Associations were analyzed using multiple logistic regression. RESULTS 1586 patients were included. NEWS2 showed poor prediction of 'mortality' (AUC 0.686, CI 0.633-0.739) and adequate prediction of 'ICU admission' (AUC 0.716, CI 0.690-0.742) and 'critical care in ED' (AUC 0.756, CI 0.732-0.780). It was strongly associated with all outcomes (all p<0.001). All NEWS2 cut-offs and the single-parameter system showed poor prediction of all outcomes (all AUCs <0.7). The single-parameter system had the strongest association with 'mortality' (OR 1.688, CI 1.052-2.708, p<0.05) and 'critical care in ED' (OR 3.267, CI 2.490-4.286, p<0.001). NEWS2 > 4 had the strongest association with 'ICU admission' (OR 2.339, CI 1.742-3.141, p<0.001). CONCLUSION For identification in order to trigger a response in the ED, outcomes closest in time seem most clinically relevant. As such, the single-parameter system had acceptable performance. NEWS2 > 4 should be considered as an additional trigger due to its association with ICU admission.
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Affiliation(s)
- Stine Engebretsen
- Emergency Department, Division of Emergencies and Critical Care, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318, Oslo, Norway
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
- Institute of Health and Society, University of Oslo, Postboks 1130 Blindern, 0318, Oslo, Norway
| | - Dag Jacobsen
- Institute of Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318, Oslo, Norway
- Department of Acute Medicine, Division of Medicine, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
| | - Valeria Vitelli
- Oslo Center for Biostatistics and Epidemiology, Department of Biostatistics, University of Oslo, Postboks 1122 Blindern, 0317, Oslo, Norway
| | - Rune Rimstad
- Medicine, Health, Patient Safety and Integration, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
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Ng-Kamstra JS, Nepogodiev D, Lawani I, Bhangu A. Perioperative mortality as a meaningful indicator: Challenges and solutions for measurement, interpretation, and health system improvement. Anaesth Crit Care Pain Med 2020; 39:673-681. [PMID: 32745634 DOI: 10.1016/j.accpm.2019.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 12/20/2022]
Abstract
Expanding global access to safe surgical and anaesthesia care is crucial to meet the health targets of the Sustainable Development Goals (SDGs). As global surgical volume increases, improving safety throughout the patient care pathway is a public health priority. At present, an estimated 4.2 million individuals die within 30 days of surgery each year, and many of these deaths are preventable. Important considerations for the collection and reporting of perioperative mortality data have been identified in the literature, but consensus has not been established on the best methodology for the quantification of excess surgical mortality at a hospital or health system level. In this narrative review, we address challenges in the use of perioperative mortality rates (POMR) for improving patient safety. First, we discuss controversies in the use of POMR as a health system indicator and suggest advantages for using a "basket" of procedure-specific mortality rates as an adjunct to gross POMR. We offer then solutions to challenges in the collection and reporting of POMR data, and propose interventions for improving care in the preoperative, operative, and postoperative periods. Finally, we discuss how health systems leaders and frontline clinicians can integrate surgical safety into both national health plans and patient care pathways to drive a sustainable safety revolution in perioperative care.
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Affiliation(s)
- Joshua S Ng-Kamstra
- Department of Critical Care Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada.
| | - Dmitri Nepogodiev
- National Institute for Health Research Global Health Research Unit on Global Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Ismaïl Lawani
- Department of Surgery and Surgical Specialties, Faculty of Health Sciences, University of Abomey Calavi, Cotonou, Benin; Rediet Shimeles Workneh, MD, Department of Anaesthesiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Aneel Bhangu
- National Institute for Health Research Global Health Research Unit on Global Surgery, University of Birmingham, Birmingham, United Kingdom
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Xiong Y, Dai W, Yu R, Liang L, Peng L. Physician awareness and attitudes regarding early warning score systems in mainland China: a cross-sectional study. Singapore Med J 2020; 63:162-166. [PMID: 32668838 DOI: 10.11622/smedj.2020107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The purpose of the study was to assess the application of the early warning score system (EWS-S) and gauge physician awareness, perceptions of necessity, and attitude regarding these tools based on previously experienced unnoticed clinical deterioration (CDET). METHODS A cross-sectional survey was carried out via an online questionnaire at a large 3,500-bed Class 3A general hospital in China. A total of 299 physicians of adult general wards were asked to answer a translated questionnaire that was localised from the original version. Demographic profiles were included as well as three other sections assessing awareness of CDET/EWS-S and gauging attitudes towards and perceptions of the necessity of EWS-S at our hospital. RESULTS There was a high level of physician awareness of the CDET problem. Most physicians knew about the existence of a systematic assessment tool for clinical application. Physicians with previous experience in reanimation, unplanned transfer to intensive care unit (UTICU) and/or death tended to consider EWS-S to be necessary in attentive and well-trained staff (p < 0.05). Physicians who had previous experience with UTICU were more likely to recommend implementing EWS-S in their wards compared with those without such experience (p < 0.05). CONCLUSION Most physicians have positive attitudes towards EWS-S. However, their awareness should be further heightened. Physicians who had previous experience with CDET/UTICU were more likely to employ EWS-S in their clinical practices. To better facilitate the implementation of EWS-S in Chinese hospitals, existing facilities, policy supports, standardised managements and the development of information systems should be strengthened.
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Affiliation(s)
- Yang Xiong
- Paediatric Ward, Xiangya Hospital, Central South University, Hunan, China
| | - Weiwei Dai
- Paediatric Ward, Xiangya Hospital, Central South University, Hunan, China
| | - Renhe Yu
- Xiangya School of Public Health, Central South University, Hunan, China
| | - Lingling Liang
- Orthopedics Department, the Sixth Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Lingli Peng
- Orthopedics Department, Xiangya Hospital, Central South University, Hunan, China
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Hwang JI, Chin HJ. Relationships between the National Early Warning Score 2, clinical worry and patient outcome at discharge: Retrospective observational study. J Clin Nurs 2020; 29:3774-3789. [PMID: 32644226 DOI: 10.1111/jocn.15408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/19/2020] [Accepted: 06/27/2020] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES To examine the performance of the National Early Warning Score 2 and composite score for clinical worry in identifying patients at risk of clinical deterioration, and to determine relationships between National Early Warning Score 2, clinical worry score and patient outcome at discharge. BACKGROUND The efficacy of early warning systems depends on patient population and care settings. Based on a theoretical framework on factors affecting clinical deterioration and patient outcomes, studies exploring the relationship between early warning systems and patient outcomes at discharge are sparse. DESIGN Retrospective observational study. METHODS A random sample of 732 medical records were reviewed. The area under the receiver operating characteristic curve was calculated to evaluate predictive abilities regarding the events of unanticipated in-hospital mortality, unplanned intensive care unit/ higher dependency bed admission and cardiac arrest. Multiple logistic regression analyses were performed to determine relationships between National Early Warning Score 2, clinical worry score and patient outcome. Reporting followed the STROBE checklist. RESULTS National Early Warning Score 2 and clinical worry score significantly predicted the events within 24 hr of the assessment. After controlling for other patient, treatment and organisational characteristics, National Early Warning Score 2 was a significant factor associated with patient outcome, but clinical worry score was not. Specifically, patients at high risk based on National Early Warning Score 2 were less likely to have improved outcome. CONCLUSIONS National Early Warning Score 2 and clinical worry score performed well for predicting deteriorating condition of patients. National Early Warning Score 2 was significantly associated with patient outcome. It can be used for efficient patient management for safe, quality care. RELEVANCE TO CLINICAL PRACTICE National Early Warning Score 2 can be used for early assessment of not only clinical deterioration but also patient outcome and provide timely intervention, when coupled with clinical worry score.
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Affiliation(s)
- Jee-In Hwang
- College of Nursing Science, Kyung Hee University, Seoul, South Korea
| | - Ho Jun Chin
- Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam-Si, South Korea
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Association between National Early Warning Scores in primary care and clinical outcomes: an observational study in UK primary and secondary care. Br J Gen Pract 2020; 70:e374-e380. [PMID: 32253189 PMCID: PMC7141816 DOI: 10.3399/bjgp20x709337] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 01/07/2020] [Indexed: 01/14/2023] Open
Abstract
Background NHS England has mandated use of the National Early Warning Score (NEWS), more recently NEWS2, in acute settings, and suggested its use in primary care. However, there is reluctance from GPs to adopt NEWS/NEWS2. Aim To assess whether NEWS calculated at the point of GP referral into hospital is associated with outcomes in secondary care. Design and setting An observational study using routinely collected data from primary and secondary care. Method NEWS values were prospectively collected for 13 047 GP referrals into acute care between July 2017 and December 2018. NEWS values were examined and multivariate linear and logistic regression used to assess associations with process measures and clinical outcomes. Results Higher NEWS values were associated with faster conveyance for patients travelling by ambulance, for example, median 94 minutes (interquartile range [IQR] 69–139) for NEWS ≥7; median 132 minutes, (IQR 84–236) for NEWS = 0 to 2); faster time from hospital arrival to medical review (54 minutes [IQR 25–114] for NEWS ≥7; 78 minutes [IQR 34–158] for NEWS = 0 to 2); as well as increased length of stay (5 days [IQR 2–11] versus 1 day [IQR 0–5]); intensive care unit admissions (2.0% versus 0.5%); sepsis diagnosis (11.7% versus 2.5%); and mortality, for example, 30-day mortality 12.0% versus 4.1% for NEWS ≥7 versus NEWS = 0 to 2, respectively. On average, for patients referred without a NEWS value (NEWS = NR), most clinical outcomes were comparable with patients with NEWS = 3 to 4, but ambulance conveyance time and time to medical review were comparable with patients with NEWS = 0 to 2. Conclusion This study has demonstrated that higher NEWS values calculated at GP referral into hospital are associated with a faster medical review and poorer clinical outcomes.
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Implementation of the National Early Warning Score in patients with suspicion of sepsis: evaluation of a system-wide quality improvement project. Br J Gen Pract 2020; 70:e381-e388. [PMID: 32269043 PMCID: PMC7147668 DOI: 10.3399/bjgp20x709349] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/06/2020] [Indexed: 11/04/2022] Open
Abstract
Background The National Early Warning Score (NEWS) was introduced to standardise early warning scores (EWS) in England. It has been recommended that NEWS should be used in pre-hospital care but there is no published evidence that this improves outcomes. In 2015, the West of England Academic Health Science Network region standardised to NEWS across all healthcare settings. Calculation of NEWS was recommended for acutely unwell patients at referral into secondary care. Aim To evaluate whether implementation of NEWS across a healthcare system affects outcomes, specifically addressing the effect on mortality in patients with suspicion of sepsis (SOS). Design and setting A quality improvement project undertaken across the West of England from March 2015 to March 2019, with the aim of standardising to NEWS in secondary care and introducing NEWS into community and primary care. Method Data from the national dashboard for SOS for the West of England were examined over time and compared to the rest of England. Quality improvement methodology and statistical process control charts were used to measure improvement. Results There was a reduction in mortality in the SOS cohort in the West of England, which was not seen in the rest of England over the time period of the project. Admissions did not increase. By March 2019, the West of England had the lowest mortality in the SOS cohort in England. Conclusion To the authors’ knowledge, this is the first study demonstrating that use of NEWS in pre-hospital care is associated with improved outcomes in patients with SOS.
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[Internal hospital emergency management : Concepts for optimization of patient safety in hospitals]. Anaesthesist 2020; 69:702-711. [PMID: 32447431 DOI: 10.1007/s00101-020-00795-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Critical incidents in hospitals can often be predicted hours before the event and can mostly be detected earlier and presumably avoided. Quality management programs from US hospitals to reduce deaths following a severe postoperative complication (failure to rescue, FTR), have in this form not yet become established in Germany. A sensitive score-based early warning system for looming complications is decisive for successful in-hospital emergency management. In addition to measurement rounds where the frequency is adapted to the severity, this includes effective communication of the results to the ward physician, who in the best case scenario solves the problem alone. If the deployment of a medical rapid response emergency team (MET) is necessary, there must be clear chain of alarm pathways and the personnel on the ward must be able to take initial bridging action until the MET arrives. The MET provides 24/7 emergency and intensive medical expertise for peripheral wards and must be familiar with the location, well-equipped and trained. Communication skills are particularly required not only to be able to handle the immediate emergency situation but also to organize the downstream diagnostics and escalation of treatment; however, the MET is only one of the links in the in-hospital rescue chain, which can only improve the patient outcome when alerted in a timely manner. Feedback systems, such as participation in the German Resuscitation Registry, allow reflection of one's own performance in a national comparison. The chances offered by a MET will only be fully realized when it is integrated into an in-hospital emergency concept and this determines the added value for patient safety.
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Shoaib M, Chalmers L, Richards T, Carison J, Leman P. Evaluation of calling criteria for the rapid response system utilising single versus multiple physiological parameter disturbances. Intern Med J 2020; 51:1117-1125. [PMID: 32388901 DOI: 10.1111/imj.14893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 04/02/2020] [Accepted: 04/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Adult Deterioration Detection System for Medical Emergency Team (MET) activation is widely used and includes single parameter (SP-MET) and multiple parameter (MP-MET) disturbances. Whether the patient characteristics, interventions and outcomes differ for SP-MET compared with MP-MET is uncertain. AIMS To describe MET interventions and outcomes of SP versus MP MET in the Acute Medical Unit (AMU) of a tertiary care hospital. METHODS Retrospective audit over 6 months comparing SP-MET and MP-MET groups. RESULTS SP-MET constituted 64.1% (168) of 262 AMU MET calls, most commonly for hypotension (35.5%) and tachycardia (14.1%). There were no significant differences in demographic and disease characteristics between the two groups. Common interventions included fluid/electrolyte replacement in 139 (52%), oxygen therapy in 46 (17%) and non-invasive ventilation in 33 (13%) patients. After MET intervention, 82.4% patients stayed on the ward, 8.4% died/were palliated, 6.5% were transferred to the Intensive Care Unit (ICU) and 2.7% patients required urgent transfer to the theatre for intervention. SP-MET patients were more likely to remain on the ward (88.7% vs 71.3%; P = 0.001), receive ward-based interventions (85.1% vs 61.7%; P < 0.001) and less likely to experience death/palliation (4.2% vs 16%, P = 0.001) compared with the MP-MET group. MP-MET were independently associated with negative outcomes (OR 3.10; 95% CI 1.60-6.00). CONCLUSION SP-MET identify a cohort of patients at lower risk of requiring escalation of care and ICU admission. Given the resource intensity of MET activation, further research is warranted to determine whether alternative response strategies are appropriate for selected SP disturbances.
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Affiliation(s)
- Muhammad Shoaib
- Acute Medical Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Leanne Chalmers
- School of Pharmacy and Biomedical Sciences, Faculty of Health Sciences, Curtin University, Western Australia, Australia
| | - Tobias Richards
- Acute Medical Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - John Carison
- The University of Notre Dame, Perth, Western Australia, Australia
| | - Peter Leman
- Acute Medical Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Agulnik A, Gossett J, Carrillo AK, Kang G, Morrison RR. Abnormal Vital Signs Predict Critical Deterioration in Hospitalized Pediatric Hematology-Oncology and Post-hematopoietic Cell Transplant Patients. Front Oncol 2020; 10:354. [PMID: 32266139 PMCID: PMC7105633 DOI: 10.3389/fonc.2020.00354] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 02/28/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction: Hospitalized pediatric hematology-oncology and post-hematopoietic cell transplant (HCT) patients have frequent deterioration requiring Pediatric Intensive Care Unit (PICU) care. Critical deterioration (CD), defined as unplanned PICU transfer requiring life-sustaining interventions within 12 h, is a pragmatic metric to evaluate emergency response systems (ERS) in pediatrics, however, it has not been investigated in these patients. The goal of this study was to evaluate if CD is an appropriate metric to assess effectiveness of ERS in pediatric hematology-oncology and post-HCT patients and if it is preceded by an actionable period of vital sign changes. Methods: A retrospective review of all unplanned PICU transfers and floor cardiopulmonary arrests in a dedicated pediatric hematology-oncology hospital between August 2014 and July 2016. Vital signs and physical exam findings 48 h prior to events were converted to Pediatric Early Warning System-Like Scores (PEWS-LS) using cardiovascular, respiratory, and neurologic criteria. Results: There were 220 deterioration events, with 107 (48.6%) meeting criteria for CD, representing a rate of 2.98 per 1,000-inpatient-days. Using the first event per hospitalization (n = 184), patients with CD had higher mortality (17.4 vs. 7.6%, p = 0.045), fewer median ICU-free-days (21 vs. 24, p = 0.011), ventilator-free-days (25 vs. 28, p < 0.001), and vasoactive-free-days (27 vs. 28, p < 0.001). Using vital sign data 48 h prior to deterioration events, those with CD had higher PEWS-LS on PICU admission (p < 0.001), spent more time with elevated PEWS-LS prior to PICU transfer (p = 0.008 to 0.023) and had a longer time from first abnormal PEWS-LS (p = 0.007 to 0.043). Significant difference between the two groups was observed as early as 4 h prior to the event (p = 0.047). Conclusion: Hospitalized pediatric hematology-oncology and post-HCT patients have frequent deterioration resulting in a high mortality. In these patients, CD is over 13 times more common than floor cardiopulmonary arrests and associated with higher mortality and fewer event-free days, making it a useful metric in these patients. CD is preceded by a long duration of abnormal vital signs, making it potentially preventable through earlier recognition.
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Affiliation(s)
- Asya Agulnik
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States.,Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Jeffrey Gossett
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Angela K Carrillo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - R Ray Morrison
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, United States
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Butler ZA. Implementing the National Early Warning Score 2 into pre-registration nurse education. Nurs Stand 2020; 35:70-75. [PMID: 32064796 DOI: 10.7748/ns.2020.e11470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 06/10/2023]
Abstract
Recognising signs of deteriorating health in patients and responding to them appropriately are crucial nursing competencies. In acute care, failure to detect and act promptly on deterioration can lead to the patient's death. To achieve clinical competence, nursing students require training in the use of techniques for monitoring physiological observations as well as protocols that enable them to respond to deterioration. The use of early warning scores has been advocated to standardise the methods and frequency of patient monitoring in acute care settings. In 2012, the Royal College of Physicians developed the National Early Warning Score (NEWS), which was updated in 2017 and known as NEWS2. This early warning score is used in acute hospitals in England, Scotland, Wales and Northern Ireland. This article explores the benefits and challenges of using NEWS2 as an educational tool in pre-registration nursing programmes to support nursing students in recognising and responding to deteriorating health.
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Affiliation(s)
- Zoe Abigail Butler
- Department of Nursing, Health and Professional Practice, University of Cumbria, Lancaster, Lancashire, England
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Posthuma LM, Visscher MJ, Hollmann MW, Preckel B. Monitoring of High- and Intermediate-Risk Surgical Patients. Anesth Analg 2020; 129:1185-1190. [PMID: 31361670 DOI: 10.1213/ane.0000000000004345] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Linda Maria Posthuma
- From the Department of Anesthesiology, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
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Kia A, Timsina P, Joshi HN, Klang E, Gupta RR, Freeman RM, Reich DL, Tomlinson MS, Dudley JT, Kohli-Seth R, Mazumdar M, Levin MA. MEWS++: Enhancing the Prediction of Clinical Deterioration in Admitted Patients through a Machine Learning Model. J Clin Med 2020; 9:jcm9020343. [PMID: 32012659 PMCID: PMC7073544 DOI: 10.3390/jcm9020343] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 01/08/2020] [Accepted: 01/17/2020] [Indexed: 01/21/2023] Open
Abstract
Early detection of patients at risk for clinical deterioration is crucial for timely intervention. Traditional detection systems rely on a limited set of variables and are unable to predict the time of decline. We describe a machine learning model called MEWS++ that enables the identification of patients at risk of escalation of care or death six hours prior to the event. A retrospective single-center cohort study was conducted from July 2011 to July 2017 of adult (age > 18) inpatients excluding psychiatric, parturient, and hospice patients. Three machine learning models were trained and tested: random forest (RF), linear support vector machine, and logistic regression. We compared the models’ performance to the traditional Modified Early Warning Score (MEWS) using sensitivity, specificity, and Area Under the Curve for Receiver Operating Characteristic (AUC-ROC) and Precision-Recall curves (AUC-PR). The primary outcome was escalation of care from a floor bed to an intensive care or step-down unit, or death, within 6 h. A total of 96,645 patients with 157,984 hospital encounters and 244,343 bed movements were included. Overall rate of escalation or death was 3.4%. The RF model had the best performance with sensitivity 81.6%, specificity 75.5%, AUC-ROC of 0.85, and AUC-PR of 0.37. Compared to traditional MEWS, sensitivity increased 37%, specificity increased 11%, and AUC-ROC increased 14%. This study found that using machine learning and readily available clinical data, clinical deterioration or death can be predicted 6 h prior to the event. The model we developed can warn of patient deterioration hours before the event, thus helping make timely clinical decisions.
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Affiliation(s)
- Arash Kia
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Prem Timsina
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Himanshu N. Joshi
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Eyal Klang
- Department of Diagnostic Imaging, The Chaim Sheba Medical Center at Tel HaShomer, Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan 52662, Israel
| | - Rohit R. Gupta
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Robert M. Freeman
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David L Reich
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Max S Tomlinson
- Department of Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Joel T Dudley
- Department of Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Roopa Kohli-Seth
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Matthew A Levin
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Correspondence: ; Tel.: +212-241-8382
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Viglino D, L'her E, Maltais F, Maignan M, Lellouche F. Evaluation of a new respiratory monitoring tool "Early Warning ScoreO 2" for patients admitted at the emergency department with dyspnea. Resuscitation 2020; 148:59-65. [PMID: 31945431 DOI: 10.1016/j.resuscitation.2020.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/10/2019] [Accepted: 01/02/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Many scores derived from Early Warning Scores have been developed to detect patients at risk of poor outcome. Few of these scores incorporate the oxygen flow rate while this is a major marker in patients with respiratory complaint. We developed and evaluated a new automatable monitoring tool (Early Warning Score O2: EWS.O2) that incorporates cardio-respiratory parameters (Respiratory rate, Heart rate, SpO2, and FiO2 derived from oxygen flow rate), aiming to achieve early detection of poor outcome among patients with dyspnea. METHODS All patients presenting at an emergency department for dyspnea from June 2011 to June 2018 with available initial value (nurse triage) of respiratory parameters were included. Our primary endpoint was a composite criterion including the use of non-invasive ventilation, ICU admission and death. The Area under the Receiver Operating Characteristic curve (AUROC) of the SpO2/FiO2 index, NEWS, NEWS2, and the EWS.O2 were compared, including in subgroup analysis by final diagnosis or oxygen supplementation. RESULTS Among the 1729 patients retrieved, the composite outcome was observed in 288 (16.7%). The EWS.O2 displayed better or comparable predictive accuracy at triage (AUROC: 0.704, 95% CI 0.672-0.736) compared to NEWS (0.662, p < 0.01), NEWS2 (0.672, p = 0.02) and SpO2/FiO2 (0.695, p = 0.46). CONCLUSIONS This new ScoreO2 is equivalent or superior to common early warning scores and index to predict poor outcome at first medical contact. This score may be automatically and continuously recorded with new closed-loop devices to titrate oxygen flow. Further prospective studies will allow to verify its accuracy at multiple time points of the patient's journey.
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Affiliation(s)
- Damien Viglino
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, Québec, Canada; Grenoble-Alpes University Hospital, HP2 Laboratory INSERM U1042, Grenoble, France
| | - Erwan L'her
- Medical Intensive Care, CHRU de Brest-La Cavale Blanche, Brest, France; LATIM INSERM UMR 1101, FHU Techsan, Université de Bretagne Occidentale, Brest, France
| | - François Maltais
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, Québec, Canada
| | - Maxime Maignan
- Grenoble-Alpes University Hospital, HP2 Laboratory INSERM U1042, Grenoble, France
| | - François Lellouche
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, Québec, Canada.
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Ye C, Wang O, Liu M, Zheng L, Xia M, Hao S, Jin B, Jin H, Zhu C, Huang CJ, Gao P, Ellrodt G, Brennan D, Stearns F, Sylvester KG, Widen E, McElhinney DB, Ling X. A Real-Time Early Warning System for Monitoring Inpatient Mortality Risk: Prospective Study Using Electronic Medical Record Data. J Med Internet Res 2019; 21:e13719. [PMID: 31278734 PMCID: PMC6640073 DOI: 10.2196/13719] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/08/2019] [Accepted: 05/25/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The rapid deterioration observed in the condition of some hospitalized patients can be attributed to either disease progression or imperfect triage and level of care assignment after their admission. An early warning system (EWS) to identify patients at high risk of subsequent intrahospital death can be an effective tool for ensuring patient safety and quality of care and reducing avoidable harm and costs. OBJECTIVE The aim of this study was to prospectively validate a real-time EWS designed to predict patients at high risk of inpatient mortality during their hospital episodes. METHODS Data were collected from the system-wide electronic medical record (EMR) of two acute Berkshire Health System hospitals, comprising 54,246 inpatient admissions from January 1, 2015, to September 30, 2017, of which 2.30% (1248/54,246) resulted in intrahospital deaths. Multiple machine learning methods (linear and nonlinear) were explored and compared. The tree-based random forest method was selected to develop the predictive application for the intrahospital mortality assessment. After constructing the model, we prospectively validated the algorithms as a real-time inpatient EWS for mortality. RESULTS The EWS algorithm scored patients' daily and long-term risk of inpatient mortality probability after admission and stratified them into distinct risk groups. In the prospective validation, the EWS prospectively attained a c-statistic of 0.884, where 99 encounters were captured in the highest risk group, 69% (68/99) of whom died during the episodes. It accurately predicted the possibility of death for the top 13.3% (34/255) of the patients at least 40.8 hours before death. Important clinical utilization features, together with coded diagnoses, vital signs, and laboratory test results were recognized as impactful predictors in the final EWS. CONCLUSIONS In this study, we prospectively demonstrated the capability of the newly-designed EWS to monitor and alert clinicians about patients at high risk of in-hospital death in real time, thereby providing opportunities for timely interventions. This real-time EWS is able to assist clinical decision making and enable more actionable and effective individualized care for patients' better health outcomes in target medical facilities.
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Affiliation(s)
- Chengyin Ye
- Department of Health Management, Hangzhou Normal University, Hangzhou, China
| | - Oliver Wang
- HBI Solutions Inc, Palo Alto, CA, United States
| | - Modi Liu
- HBI Solutions Inc, Palo Alto, CA, United States
| | - Le Zheng
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,Clinical and Translational Research Program, Betty Irene Moore Children's Heart Center, Lucile Packard Children's Hospital, Palo Alto, CA, United States
| | - Minjie Xia
- HBI Solutions Inc, Palo Alto, CA, United States
| | - Shiying Hao
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,Clinical and Translational Research Program, Betty Irene Moore Children's Heart Center, Lucile Packard Children's Hospital, Palo Alto, CA, United States
| | - Bo Jin
- HBI Solutions Inc, Palo Alto, CA, United States
| | - Hua Jin
- HBI Solutions Inc, Palo Alto, CA, United States
| | | | - Chao Jung Huang
- National Taiwan University-Stanford Joint Program Office of AI in Biotechnology, Ministry of Science and Technology Joint Research Center for Artificial Intelligence Technology and All Vista Healthcare, Taipei, Taiwan
| | - Peng Gao
- Shandong University of Traditional Chinese Medicine, Shandong, China.,Department of Surgery, Stanford University, Stanford, CA, United States
| | - Gray Ellrodt
- Department of Medicine, Berkshire Medical Center, Pittsfield, MA, United States
| | - Denny Brennan
- Massachusetts Health Data Consortium, Waltham, CA, United States
| | | | - Karl G Sylvester
- Department of Surgery, Stanford University, Stanford, CA, United States
| | - Eric Widen
- HBI Solutions Inc, Palo Alto, CA, United States
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,Clinical and Translational Research Program, Betty Irene Moore Children's Heart Center, Lucile Packard Children's Hospital, Palo Alto, CA, United States
| | - Xuefeng Ling
- Clinical and Translational Research Program, Betty Irene Moore Children's Heart Center, Lucile Packard Children's Hospital, Palo Alto, CA, United States.,Department of Surgery, Stanford University, Stanford, CA, United States
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Al-Kalaldeh M, Suleiman K, Abu-Shahroor L, Al-Mawajdah H. The impact of introducing the Modified Early Warning Score ‘MEWS’ on emergency nurses’ perceived role and self-efficacy: A quasi-experimental study. Int Emerg Nurs 2019; 45:25-30. [DOI: 10.1016/j.ienj.2019.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 11/25/2022]
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