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Glover G, Metaxa V, Ostermann M. Intensive Care Unit Without Walls. Crit Care Clin 2024; 40:549-560. [PMID: 38796227 DOI: 10.1016/j.ccc.2024.03.002] [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
Critical illness is a continuum with different phases and trajectories. The "Intensive Care Unit (ICU) without walls" concept refers to a model whereby care is adjusted in response to the patient's needs, priorities, and preferences at each stage from detection, escalation, early decision making, treatment and organ support, followed by recovery and rehabilitation, within which all healthcare staff, and the patient are equal partners. The rapid response system incorporates monitoring and alerting tools, a multidisciplinary critical care outreach team and care bundles, supported with education and training, analytical and governance functions, which combine to optimise outcomes of critically ill patients, independent of location.
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Affiliation(s)
- Guy Glover
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital, Denmark Hill, SE5 9RS, London, UK
| | - Marlies Ostermann
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK.
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Gawronski O, Briassoulis G, El Ghannudi Z, Ilia S, Sánchez-Martín M, Chiusolo F, Jensen CS, Manning JC, Valla FV, Pavelescu C, Dall'Oglio I, Coad J, Sefton G. European survey on Paediatric Early Warning Systems, and other processes used to aid the recognition and response to children's deterioration on hospital wards. Nurs Crit Care 2024. [PMID: 38867428 DOI: 10.1111/nicc.13096] [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: 12/11/2023] [Revised: 05/03/2024] [Accepted: 05/13/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Internationally, there is an increasing trend in using Rapid Response Systems (RRS) to stabilize in-patient deterioration. Despite a growing evidence base, there remains limited understanding of the processes in place to aid the early recognition and response to deteriorating children in hospitals across Europe. AIM/S To describe the processes in place for early recognition and response to in-patient deterioration in children in European hospitals. STUDY DESIGN A cross-sectional opportunistic multi-centre European study, of hospitals with paediatric in-patients, using a descriptive self-reported, web-based survey, was conducted between September 2021 and March 2022. The sampling method used chain referral through members of European and national societies, led by country leads. The survey instrument was an adaptation to the survey of Recognition and Response Systems in Australia. The study received ethics approval. Descriptive analysis and Chi-squared tests were performed to compare results in European regions. RESULTS A total of 185 questionnaires from 21 European countries were received. The majority of respondents (n = 153, 83%) reported having written policies, protocols, or guidelines, regarding the measurement of physiological observations. Over half (n = 120, 65%) reported that their hospital uses a Paediatric Early Warning System (PEWS) and 75 (41%) reported having a Rapid Response Team (RRT). Approximately one-third (38%) reported that their hospital collects specific data about the effectiveness of their RRS, while 100 (54%) reported providing regular training and education to support it. European regional differences existed in PEWS utilization (North = 98%, Centre = 25%, South = 44%, p < .001) and process evaluation (North = 49%, Centre = 6%, South = 36%, p < .001). CONCLUSIONS RRS practices in European hospitals are heterogeneous. Differences in the uptake of PEWS and RRS process evaluation emerged across Europe. RELEVANCE TO CLINICAL PRACTICE It is important to scope practices for the safe monitoring and management of deteriorating children in hospital across Europe. To reduce variance in practice, a consensus statement endorsed by paediatric and intensive care societies could provide guidance and resources to support PEWS implementation and for the operational governance required for continuous quality improvement.
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Affiliation(s)
- Orsola Gawronski
- Continuing Education and Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | | | - Stavroula Ilia
- School of Medicine, University of Crete, University Hospital, Heraklion, Greece
| | | | - Fabrizio Chiusolo
- Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Claus Sixtus Jensen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Research Center for Emergency Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Joseph C Manning
- University of Leicester/Nottingham University Hospitals NHS Trust. School of Healthcare, The University of Leicester, Leicester, UK
| | | | - Carmen Pavelescu
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - Immacolata Dall'Oglio
- Continuing Education and Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Jane Coad
- Queen Elizabeth Campus, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Gerri Sefton
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Nolan J, Mackay I, Nolan T, de Looze J. Medical Emergency Team call within 24 h of medical admission with a focus on sepsis: a retrospective review. Intern Med J 2024; 54:961-969. [PMID: 38288844 DOI: 10.1111/imj.16337] [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] [Received: 06/11/2023] [Accepted: 12/28/2023] [Indexed: 06/18/2024]
Abstract
BACKGROUND AND AIMS Clinical deterioration within the first 24 h of patient admission triggering a Medical Emergency Team (MET) call is a common occurrence. A greater understanding of these events, with a focus on the recognition and management of sepsis, could lead to quality improvement interventions. METHODS A retrospective observational review of general and subspecialty medical admissions triggering a MET call within 24 h of admission at a quaternary Australian hospital. RESULTS 2648 MET calls occurred (47.9/1000 admissions), 527 (20% of total MET events, 9.5/1000 admissions) within 24 h of admission, with the trigger more likely to be hypotension (odds ratio: 1.5, P = 0.0013). There were 263 MET calls to 217 individual medical patients within 24 h of admission, of which 84 (38.7%) were admitted with suspected infection, 69% of which fulfilled sepsis criteria. Of these, 36.2% received antimicrobial therapy within the recommended timeframe and 39.6% received antibiotics in line with hospital guidelines. Sepsis was initially missed in 11% of patients. Afferent limb failure occurred in 29% of patients with 40.5% experiencing a failure of the ward-based response to deterioration prior to MET call. Median hospital length of stay was increased in patients admitted with suspected infection (7 vs 5 days, P = 0.015) and in those with sepsis not receiving antimicrobial therapy within guideline timeframes (9 vs 4 days, P = 0.017). CONCLUSION There is a significant opportunity to improve care for patients who trigger a MET within 24 h of admission. This study supports the implementation of a hospital sepsis management guideline.
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Affiliation(s)
- James Nolan
- Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Ian Mackay
- Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Timothy Nolan
- The Cairns Hospital, Cairns, Queensland, Australia
- Griffith University, Gold Coast, Queensland, Australia
| | - Julian de Looze
- Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Messmer AS, Baertsch G, Cioccari L. Prevalence and characteristics of medical emergency teams in Switzerland: a nationwide survey of intensive care units. Minerva Anestesiol 2024; 90:409-416. [PMID: 38771165 DOI: 10.23736/s0375-9393.24.17876-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Medical Emergency Teams (METs) have been implemented in many hospitals worldwide and are considered an integral part of the hospital patient safety system. However, data on prevalence, staffing and activation criteria of METs are scarce. Such data are important as they may help to identify areas of quality improvement and barriers to implementation of rapid response systems (RRS). This survey aimed to analyze current characteristics, prevalence, and organization of METs in Switzerland. METHODS We conducted a cross-sectional nationwide online survey, inviting physicians' and nurses' representatives from all registered adult intensive care units (ICU) in Switzerland. RESULTS Of the 74 hospitals invited to participate in the survey, 57 responded (response rate 77%). We obtained 82 individual responses (from 50 physicians and 32 nurses). Twenty-five hospitals (44%) have a MET in place. In most Swiss hospitals, METs are composed of ICU consultants (64%) and ICU nurses (40%) and are activated by phone, with a usual response time of less than 10 minutes. The most common triggers are single abnormal vital signs (80%), while multiple-parameter warning scores are less commonly used (28%). While more than half of the nurses have regular trainings for their MET members (57%), most MET physicians (63%) do not. Systematic data collection of MET calls occurs in only 43% of institutions. Finally, the most common reasons for not having a MET are staff shortage (44%) and lack of funding (19%). CONCLUSIONS Less than 50% of Swiss hospitals with an adult ICU have a MET in place. METs in Switzerland typically include an ICU doctor and an ICU nurse and are available 24/7. Major barriers to MET introduction are staff shortage and lack of funding.
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Affiliation(s)
- Anna S Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland -
| | - Gianna Baertsch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luca Cioccari
- Department of Intensive Care Medicine, Kantonsspital Aarau, Aarau, Switzerland
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Lin CS, Liu WT, Tsai DJ, Lou YS, Chang CH, Lee CC, Fang WH, Wang CC, Chen YY, Lin WS, Cheng CC, Lee CC, Wang CH, Tsai CS, Lin SH, Lin C. AI-enabled electrocardiography alert intervention and all-cause mortality: a pragmatic randomized clinical trial. Nat Med 2024; 30:1461-1470. [PMID: 38684860 DOI: 10.1038/s41591-024-02961-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 03/29/2024] [Indexed: 05/02/2024]
Abstract
The early identification of vulnerable patients has the potential to improve outcomes but poses a substantial challenge in clinical practice. This study evaluated the ability of an artificial intelligence (AI)-enabled electrocardiogram (ECG) to identify hospitalized patients with a high risk of mortality in a multisite randomized controlled trial involving 39 physicians and 15,965 patients. The AI-ECG alert intervention included an AI report and warning messages delivered to the physicians, flagging patients predicted to be at high risk of mortality. The trial met its primary outcome, finding that implementation of the AI-ECG alert was associated with a significant reduction in all-cause mortality within 90 days: 3.6% patients in the intervention group died within 90 days, compared to 4.3% in the control group (4.3%) (hazard ratio (HR) = 0.83, 95% confidence interval (CI) = 0.70-0.99). A prespecified analysis showed that reduction in all-cause mortality associated with the AI-ECG alert was observed primarily in patients with high-risk ECGs (HR = 0.69, 95% CI = 0.53-0.90). In analyses of secondary outcomes, patients in the intervention group with high-risk ECGs received increased levels of intensive care compared to the control group; for the high-risk ECG group of patients, implementation of the AI-ECG alert was associated with a significant reduction in the risk of cardiac death (0.2% in the intervention arm versus 2.4% in the control arm, HR = 0.07, 95% CI = 0.01-0.56). While the precise means by which implementation of the AI-ECG alert led to decreased mortality are to be fully elucidated, these results indicate that such implementation assists in the detection of high-risk patients, prompting timely clinical care and reducing mortality. ClinicalTrials.gov registration: NCT05118035 .
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Affiliation(s)
- Chin-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Medical Technology Education Center, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Wei-Ting Liu
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Dung-Jang Tsai
- Medical Technology Education Center, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Artificial Intelligence and Internet of Things, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Statistics and Information Science, Fu Jen Catholic University, New Taipei City, Taiwan, Republic of China
| | - Yu-Sheng Lou
- Department of Artificial Intelligence and Internet of Things, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chiao-Hsiang Chang
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chiao-Chin Lee
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Wen-Hui Fang
- Department of Artificial Intelligence and Internet of Things, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chih-Chia Wang
- Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yen-Yuan Chen
- Department and Graduate Institute of Medical Education and Bioethics, National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China
| | - Wei-Shiang Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Cheng-Chung Cheng
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chia-Cheng Lee
- Department of Medical Informatics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Division of Colorectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chih-Hung Wang
- Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chien-Sung Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Shih-Hua Lin
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chin Lin
- Medical Technology Education Center, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China.
- Department of Artificial Intelligence and Internet of Things, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China.
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, Republic of China.
- Graduate Institute of Aerospace and Undersea Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China.
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Rajpurkar M, Rosovsky RP, Williams S, Chan AKC, van Ommen CH, Faustino EVS, White M, Parikh M, Sirachainan N, Biss T, Goldenberg NA. Considerations for instituting pediatric pulmonary embolism response teams: A tool kit. Thromb Res 2024; 236:97-107. [PMID: 38417301 DOI: 10.1016/j.thromres.2024.02.019] [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] [Received: 12/21/2023] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 03/01/2024]
Abstract
The incidence of pediatric pulmonary embolism (PE) has increased by 200 % in the last decade, but at a single center, it is still infrequent. Given the unique epidemiologic features of pediatric PE, diagnosis is often delayed, and the management is empiric, based on individual physician experience or preference. Thus, there is a strong need for center-specific uniform management of pediatric PE patients. In adults, the development of pulmonary embolism response teams (PERTs) or PE critical care pathways has shortened the time to diagnosis and the initiation of definitive management. Evidence to support an improvement in PE outcomes after the development of PERTs does not exist in children. Nonetheless, we have summarized the practical practice guidelines that physicians and institutions can adopt to establish their institutional PERTs or critical pathways. We also provide strategies for resource-challenged institutions for partnering with centers with expertise in the management of pediatric PE.
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Affiliation(s)
- Madhvi Rajpurkar
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Central Michigan University, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA.
| | - Rachel P Rosovsky
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Suzan Williams
- Division of Hematology/Oncology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Canada
| | | | - C Heleen van Ommen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - E Vincent S Faustino
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Melissa White
- Division of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mihir Parikh
- Department of Pediatric Anesthesiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nongnuch Sirachainan
- Division of Hematology/Oncology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand
| | - Tina Biss
- Department of Haematology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Neil A Goldenberg
- Department of Pediatrics and Medicine, Division of Hematology, Johns Hopkins, University School of Medicine, Baltimore, MD, USA; Johns Hopkins All Children's Institute for Clinical and Translational Research, Cancer and Blood Disorder Institute, and Heart Institute, Johns Hopkins All Children's, Hospital, St. Petersburg, FL, USA
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Hecht JD, Yoder LH, Danesh V, Heitkemper EM. A systematic review of the facilitators and barriers to rapid response team activation. Worldviews Evid Based Nurs 2024; 21:148-157. [PMID: 38159058 DOI: 10.1111/wvn.12700] [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] [Received: 08/09/2023] [Revised: 11/06/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Outcomes associated with rapid response teams (RRTs) are inconsistent. This may be due to underlying facilitators and barriers to RRT activation that are affected by team leaders and health systems. AIMS The aim of this study was to synthesize the published research about facilitators and barriers to nurse-led RRT activation in the United States (U.S.). METHODS A systematic review was conducted. Four databases were searched from January 2000 to June 2023 for peer-reviewed quantitative, qualitative, and mixed methods studies reporting facilitators and barriers to RRT activation. Studies conducted outside the U.S. or with physician-led teams were excluded. RESULTS Twenty-five studies met criteria representing 240,140 participants that included clinicians and hospitalized adults. Three domains of facilitators and barriers to RRT activation were identified: (1) hospital infrastructure, (2) clinician culture, and (3) nurses' beliefs, attributes, and knowledge. Categories were identified within each domain. The categories of perceived benefits and positive beliefs about RRTs, knowing when to activate the RRT, and hospital-wide policies and practices most facilitated activation, whereas the categories of negative perceptions and concerns about RRTs and uncertainties surrounding RRT activation were the dominant barriers. LINKING EVIDENCE TO ACTION Facilitators and barriers to RRT activation were interrelated. Some facilitators like hospital leader and physician support of RRTs became barriers when absent. Intradisciplinary communication and collaboration between nurses can positively and negatively impact RRT activation. The expertise of RRT nurses should be further studied.
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Affiliation(s)
- Jonathan D Hecht
- The University of Texas at Austin School of Nursing, Austin, Texas, USA
| | - Linda H Yoder
- The University of Texas at Austin School of Nursing, Austin, Texas, USA
| | - Valerie Danesh
- The University of Texas at Austin School of Nursing, Austin, Texas, USA
- Baylor Scott & White Health, Dallas, Texas, USA
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Wang YM, Chiu IM, Chuang YP, Cheng CY, Lin CF, Cheng FJ, Lin CF, Li CJ. RAPID-ED: A predictive model for risk assessment of patient's early in-hospital deterioration from emergency department. Resusc Plus 2024; 17:100570. [PMID: 38357677 PMCID: PMC10864627 DOI: 10.1016/j.resplu.2024.100570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 02/16/2024] Open
Abstract
Introduction The objective of this multi-center retrospective cohort study was to devise a predictive tool known as RAPID-ED. This model identifies non-traumatic adult patients at significant risk for cardiac arrest within 48 hours post-admission from the emergency department. Methods Data from 224,413 patients admitted through the emergency department (2016-2020) was analyzed, incorporating vital signs, lab tests, and administered therapies. A multivariable regression model was devised to anticipate early cardiac arrest. The efficacy of the RAPID-ED model was evaluated against traditional scoring systems like National Early Warning Score (NEWS) and Modified Early Warning Score (MEWS) and its predictive ability was gauged via the area under the receiver operating characteristic curve (AUC) in both hold-out validation set and external validation set. Results RAPID-ED outperformed traditional models in predicting cardiac arrest with an AUC of 0.819 in the hold-out validation set and 0.807 in the external validation set. In this critical care update, RAPID-ED offers an innovative approach to assessing patient risk, aiding emergency physicians in post-discharge care decisions from the emergency department. High-risk score patients (≥13) may benefit from early ICU admission for intensive monitoring. Conclusion As we progress with advancements in critical care, tools like RAPID-ED will prove instrumental in refining care strategies for critically ill patients, fostering an improved prognosis and potentially mitigating mortality rates.
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Affiliation(s)
- Yi-Min Wang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Yu-Ping Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Chi-Yung Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Chun-Fu Lin
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Chien-Fu Lin
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Chao-Jui Li
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
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Douglas C, Alexeev S, Middleton S, Gardner G, Kelly P, McInnes E, Rihari-Thomas J, Windsor C, Morton RL. Transforming nursing assessment in acute hospitals: A cluster randomised controlled trial of an evidence-based nursing core assessment (the ENCORE trial). Int J Nurs Stud 2024; 151:104690. [PMID: 38237324 DOI: 10.1016/j.ijnurstu.2024.104690] [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] [Received: 07/18/2023] [Revised: 12/31/2023] [Accepted: 01/02/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Patient safety is threatened when early signs of clinical deterioration are missed or not acted upon. This research began as a clinical-academic partnership established around a shared concern of nursing physical assessment practices on general wards and delayed recognition of clinical deterioration. The outcome was the development of a complex intervention facilitated at the ward level for proactive nursing surveillance. METHODS The evidence-based nursing core assessment (ENCORE) trial was a pragmatic cluster-randomised controlled trial. We hypothesised that ward intervention would reduce the incidence of patient rescue events (medical emergency team activations) and serious adverse events. We randomised 29 general wards in a 1:2 allocation, across 5 Australian hospitals to intervention (n = 10) and usual care wards (n = 19). Skilled facilitation over 12 months enabled practitioner-led, ward-level practice change for proactive nursing surveillance. The primary outcome was the rate of medical emergency team activations and secondary outcomes were unplanned intensive care unit admissions, on-ward resuscitations, and unexpected deaths. Outcomes were prospectively collected for 6 months following the initial 6 months of implementation. Analysis was at the patient level using generalised linear mixed models to account for clustering by ward. RESULTS We analysed 29,385 patient admissions to intervention (n = 11,792) and control (n = 17,593) wards. Adjusted models for overall effects suggested the intervention increased the rate of medical emergency team activations (adjusted incidence rate ratio 1.314; 95 % confidence interval 0.975, 1.773), although the confidence interval was compatible with a marginal decrease to a substantial increase in rate. Confidence intervals for secondary outcomes included a range of plausible effects from benefit to harm. However, considerable heterogeneity was observed in intervention effects by patient comorbidity. Among patients with few comorbid conditions in the intervention arm there was a lower medical emergency team activation rate and decreased odds of unexpected death. Among patients with multimorbidity in the intervention arm there were higher rates of medical emergency team activation and intensive care unit admissions. CONCLUSION Trial outcomes have refined our assumptions about the impact of the ENCORE intervention. The intervention appears to have protective effects for patients with low complexity where frontline teams can respond locally. It also appears to have redistributed medical emergency team activations and unplanned intensive care unit admissions, mobilising higher rates of rescue for patients with multimorbidity. TRIAL REGISTRATION NUMBER ACTRN12618001903279 (Date of registration: 22/11/2018; First participant recruited: 01/02/2019).
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Affiliation(s)
- Clint Douglas
- School of Nursing, Queensland University of Technology (QUT), Kelvin Grove, QLD 4059, Australia; Office of Nursing and Midwifery Services, Metro North Hospital and Health Service, Herston, QLD 4006, Australia.
| | - Sergey Alexeev
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2015, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia; School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Glenn Gardner
- School of Nursing, Queensland University of Technology (QUT), Kelvin Grove, QLD 4059, Australia
| | - Patrick Kelly
- The University of Sydney, Faculty of Medicine and Health, Sydney School of Public Health, Camperdown, NSW 2006, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia; School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | | | - Carol Windsor
- School of Nursing, Queensland University of Technology (QUT), Kelvin Grove, QLD 4059, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2015, Australia
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10
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Al-Harbi S. Impact of Rapid Response Teams on Pediatric Care: An Interrupted Time Series Analysis of Unplanned PICU Admissions and Cardiac Arrests. Healthcare (Basel) 2024; 12:518. [PMID: 38470629 PMCID: PMC10931051 DOI: 10.3390/healthcare12050518] [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: 12/28/2023] [Revised: 02/12/2024] [Accepted: 02/18/2024] [Indexed: 03/14/2024] Open
Abstract
Pediatric rapid response teams (RRTs) are expected to significantly lower pediatric mortality in healthcare settings. This study evaluates RRTs' effectiveness in decreasing cardiac arrests and unexpected Pediatric Intensive Care Unit (PICU) admissions. A quasi-experimental study (2014-2017) at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, involved 3261 pediatric inpatients, split into pre-intervention (1604) and post-intervention (1657) groups. Baseline pediatric warning scores and monthly data on admissions, transfers, arrests, and mortality were analyzed pre- and post-intervention. Statistical methods including bootstrapping, segmented regression, and a Zero-Inflation Poisson model were employed to ensure a comprehensive evaluation of the intervention's impact. RRT was activated 471 times, primarily for respiratory distress (29.30%), sepsis (22.30%), clinical anxiety (13.80%), and hematological abnormalities (6.7%). Family concerns triggered 0.1% of activations. Post-RRT implementation, unplanned PICU admissions significantly reduced (RR = 0.552, 95% CI 0.485-0.628, p < 0.0001), and non-ICU cardiac arrests were eliminated (RR = 0). Patient care improvement was notable, with a -9.61 coefficient for PICU admissions (95% CI: -12.65 to -6.57, p < 0.001) and a -1.641 coefficient for non-ICU cardiac arrests (95% CI: -2.22 to -1.06, p < 0.001). Sensitivity analysis showed mixed results for PICU admissions, while zero-inflation Poisson analysis confirmed a reduction in non-ICU arrests. The deployment of pediatric RRTs is associated with fewer unexpected PICU admissions and non-ICU cardiopulmonary arrests, indicating improved PICU management. Further research using robust scientific methods is necessary to conclusively determine RRTs' clinical benefits.
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Affiliation(s)
- Samah Al-Harbi
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
- Department of Pediatrics, King Abdulaziz University Hospital, Jeddah 22252, Saudi Arabia
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Churpek MM, Ingebritsen R, Carey KA, Rao SA, Murnin E, Qyli T, Oguss MK, Picart J, Penumalee L, Follman BD, Nezirova LK, Tully ST, Benjamin C, Nye C, Gilbert ER, Shah NS, Winslow CJ, Afshar M, Edelson DP. Causes, Diagnostic Testing, and Treatments Related to Clinical Deterioration Events among High-Risk Ward Patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.05.24301960. [PMID: 38370788 PMCID: PMC10871454 DOI: 10.1101/2024.02.05.24301960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
OBJECTIVE Timely intervention for clinically deteriorating ward patients requires that care teams accurately diagnose and treat their underlying medical conditions. However, the most common diagnoses leading to deterioration and the relevant therapies provided are poorly characterized. Therefore, we aimed to determine the diagnoses responsible for clinical deterioration, the relevant diagnostic tests ordered, and the treatments administered among high-risk ward patients using manual chart review. DESIGN Multicenter retrospective observational study. SETTING Inpatient medical-surgical wards at four health systems from 2006-2020 PATIENTS: Randomly selected patients (1,000 from each health system) with clinical deterioration, defined by reaching the 95th percentile of a validated early warning score, electronic Cardiac Arrest Risk Triage (eCART), were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical deterioration was confirmed by a trained reviewer or marked as a false alarm if no deterioration occurred for each patient. For true deterioration events, the condition causing deterioration, relevant diagnostic tests ordered, and treatments provided were collected. Of the 4,000 included patients, 2,484 (62%) had clinical deterioration confirmed by chart review. Sepsis was the most common cause of deterioration (41%; n=1,021), followed by arrhythmia (19%; n=473), while liver failure had the highest in-hospital mortality (41%). The most common diagnostic tests ordered were complete blood counts (47% of events), followed by chest x-rays (42%), and cultures (40%), while the most common medication orders were antimicrobials (46%), followed by fluid boluses (34%), and antiarrhythmics (19%). CONCLUSIONS We found that sepsis was the most common cause of deterioration, while liver failure had the highest mortality. Complete blood counts and chest x-rays were the most common diagnostic tests ordered, and antimicrobials and fluid boluses were the most common medication interventions. These results provide important insights for clinical decision-making at the bedside, training of rapid response teams, and the development of institutional treatment pathways for clinical deterioration. KEY POINTS Question: What are the most common diagnoses, diagnostic test orders, and treatments for ward patients experiencing clinical deterioration? Findings: In manual chart review of 2,484 encounters with deterioration across four health systems, we found that sepsis was the most common cause of clinical deterioration, followed by arrythmias, while liver failure had the highest mortality. Complete blood counts and chest x-rays were the most common diagnostic test orders, while antimicrobials and fluid boluses were the most common treatments. Meaning: Our results provide new insights into clinical deterioration events, which can inform institutional treatment pathways, rapid response team training, and patient care.
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Piasecki RJ, Hunt EA, Perrin N, Spaulding EM, Winters B, Samuel L, Davidson PM, Chandra Strobos N, Churpek M, Himmelfarb CR. Using rapid response system trigger clusters to characterize patterns of clinical deterioration among hospitalized adult patients. Resuscitation 2024; 194:110041. [PMID: 37952578 PMCID: PMC10842078 DOI: 10.1016/j.resuscitation.2023.110041] [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: 06/22/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Many rapid response system (RRS) events are activated using multiple triggers. However, the patterns in which multiple RRS triggers occur together to activate RRS events are unknown. The purpose of this study was to identify these patterns (RRS trigger clusters) and determine their association with outcomes among hospitalized adult patients. METHODS RRS events among adult patients from January 2015 to December 2019 in the Get With The Guidelines- Resuscitation registry's MET module were examined (n = 134,406). Cluster analysis methods were performed to identify RRS trigger clusters. Pearson's chi-squared and ANOVA tests were used to examine differences in patient characteristics across RRS trigger clusters. Multilevel logistic regressions were used to examine the associations between RRS trigger clusters and outcomes. RESULTS Six RRS trigger clusters were identified. Predominant RRS triggers for each cluster were: tachypnea, new onset difficulty in breathing, decreased oxygen saturation (Cluster 1); tachypnea, decreased oxygen saturation, staff concern (Cluster 2); respiratory depression, decreased oxygen saturation, mental status changes (Cluster 3); tachycardia, staff concern (Cluster 4); mental status changes (Cluster 5); hypotension, staff concern (Cluster 6). Significant differences in patient characteristics were observed across clusters. Patients in Clusters 3 and 6 had an increased likelihood of in-hospital cardiac arrest (p < 0.01). All clusters had an increased risk of mortality (p < 0.01). CONCLUSIONS We discovered six novel RRS trigger clusters with differing relationships to adverse patient outcomes. RRS trigger clusters may prove crucial in clarifying the associations between RRS events and adverse outcomes and aiding in clinician decision-making during RRS events.
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Affiliation(s)
- Rebecca J Piasecki
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States.
| | - Elizabeth A Hunt
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Nancy Perrin
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Erin M Spaulding
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Bradford Winters
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Laura Samuel
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Patricia M Davidson
- University of Wollongong Australia, Northfields Ave., Wollongong, NSW 2522, Australia
| | | | - Matthew Churpek
- University of Wisconsin-Madison, Union South, 1308 W. Dayton St., Madison, WI 53715, United States
| | - Cheryl R Himmelfarb
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
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13
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Antia A, Ndukauba C, Pius R, Gbegbaje O, Ong K. Impact of day of admission on in-hospital outcomes of cardiogenic shock. Curr Probl Cardiol 2024; 49:102140. [PMID: 37858845 DOI: 10.1016/j.cpcardiol.2023.102140] [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] [Received: 10/13/2023] [Accepted: 10/14/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND The management of cardiogenic shock (CS) requires attentiveness to details and in some cases, invasive interventions. In the past, studies have shown relationships between the day of admission and cardiovascular outcomes. We aim to analyze the trends and in-hospital outcomes of patients admitted with CS over the weekends compared to weekdays. METHOD We identified all patients with CS from the National Inpatient Sample (NIS) database between 2016 and 2020. Using multivariate logistic regression analysis, baseline demographics and in-hospital outcomes were obtained and compared by weekend or weekday admission. RESULTS Out of 854,684 CS admissions, 199,255 (23.6%) occurred on weekends. Patients admitted over the weekend had worse outcomes, including higher rates of mortality (aOR 1.09 CI 1.05 - 1.11, p<0.001), cardiac arrest (aOR 1.09 CI 1.04 -1.14, p<0.001), and respiratory failure. We also noted higher percutaneous coronary intervention (PCI) rates (aOR 1.2 CI 1.16 - 1.25, p<0.001) but lower rates of pulmonary artery catheterization (PAC) and post-procedure pneumothorax. Weekend admissions had shorter hospital lengths of stay, and they incurred lower charges ($223,222 vs. $247,908). Between 2016 and 2020, we observed a consistent downward trend in the mortality rates of the weekend and weekday CS admissions, with consistently higher weekend than weekday admissions. CONCLUSION Weekend admissions for CS are associated with worse outcomes, which have persisted for years. This now begs the question of whether physician dissatisfaction, understaffing, or burn-out are responsible for this finding.
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Affiliation(s)
- Akanimo Antia
- Department of Medicine, Lincoln Medical Center, Bronx, New York, United States of America.
| | - Chinonso Ndukauba
- Department of Medicine, Lincoln Medical Center, Bronx, New York, United States of America
| | - Ruth Pius
- Department of Medicine, Lincoln Medical Center, Bronx, New York, United States of America
| | - Oghenetejiri Gbegbaje
- Department of Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey, United States of America
| | - Kenneth Ong
- Department of Cardiology, Lincoln Medical Center, Bronx, New York, United States of America
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14
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Posthuma LM, Preckel B. Initiatives to detect and prevent death from perioperative deterioration. Curr Opin Anaesthesiol 2023; 36:676-682. [PMID: 37767926 PMCID: PMC10621647 DOI: 10.1097/aco.0000000000001312] [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: 09/29/2023]
Abstract
PURPOSE OF REVIEW This study indicates that there are differences between hospitals in detection, as well as in adequate management of postsurgical complications, a phenomenon that is described as 'failure-to-rescue'.In this review, recent initiatives to reduce failure-to-rescue in the perioperative period are described. RECENT FINDINGS Use of cognitive aids, emergency manuals, family participation as well as remote monitoring systems are measures to reduce failure-to-rescue situations. Postoperative visit of an anaesthesiologist on the ward was not shown to improve outcome, but there is still room for improvement of postoperative care. SUMMARY Improving the complete emergency chain, including monitoring, recognition and response in the afferent limb, as well as diagnostic and treatment in the efferent limb, should lead to reduced failure-to-rescue situations in the perioperative period.
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Affiliation(s)
- Linda M. Posthuma
- Department of Anesthesiology and Intensive Care Medicine, Amphia Hospital, Breda
| | - Benedikt Preckel
- Department of Anesthesiology, Amsterdam University Medical Centre, location University of Amsterdam
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam University Medical Centre, Amsterdam, The Netherlands
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15
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Lauridsen KG, Riis DN, Yeung J. Rapid response teams: Looking at the elephant through a different key hole. Resuscitation 2023; 193:110011. [PMID: 37884219 DOI: 10.1016/j.resuscitation.2023.110011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 10/28/2023]
Affiliation(s)
- Kasper G Lauridsen
- Research Center for Emergency Medicine, Aarhus University, Denmark; Department of Medicine, Randers Regional Hospital, Denmark; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, United States.
| | - Dung N Riis
- Research Center for Emergency Medicine, Aarhus University, Denmark; Department of Medicine, Randers Regional Hospital, Denmark
| | - Joyce Yeung
- University of Warwick, Warwick Medical School, United Kingdom; Department of Critical Care, University Hospitals Birmingham NHS Foundation Trust, United Kingdom
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Haegdorens F, Edwards E, So RK, Subbe CP. The third Medical Emergency Teams - Hospital outcomes in a day (METHOD3) study: The application of quality metrics for rapid response systems around the world. Resusc Plus 2023; 16:100502. [PMID: 38026138 PMCID: PMC10661606 DOI: 10.1016/j.resplu.2023.100502] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Aim This cross-sectional study aimed to assess the readiness of international hospitals to implement consensus-based quality metrics for rapid response systems (RRS) and evaluate the feasibility of collecting these metrics. Methods A digital survey was developed and distributed to hospital administrators and clinicians worldwide. The survey captured data on the recommended quality metrics for RRS and collected information on hospital characteristics. Statistical analysis included descriptive evaluations and comparisons by country and hospital type. Results A total of 109 hospitals from 11 countries participated in the survey. Most hospitals had some form of RRS in place, with multiple parameter track and trigger systems being commonly used. The survey revealed variations in the adoption of quality metrics among hospitals. Metrics related to patient-activated rapid response and organizational culture were collected less frequently. Geographical differences were observed, with hospitals in Australia and New Zealand demonstrating higher adoption of core quality metrics. Urban hospitals reported a lower number of recorded metrics compared to metropolitan and rural hospitals. Conclusion The study highlights the feasibility of collecting consensus-based quality metrics for RRS in international hospitals. However, variations in data collection and adoption of specific metrics suggest potential barriers and the need for further exploration. Standardized quality metrics are crucial for effective RRS functioning and continuous improvement in patient care. Collaborative initiatives and further research are needed to overcome barriers, enhance data collection capabilities, and facilitate knowledge sharing among healthcare providers to improve the quality and safety of RRS implementation globally.
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Affiliation(s)
- Filip Haegdorens
- Centre for Research and Innovation in Care (CRIC), University of Antwerp, Belgium
| | - Eirian Edwards
- Advanced Nurse Practitioner, Betsi Cadwaladr University Health Board, Bangor, Gwynedd, United Kingdom
| | - Ralph K. So
- Intensive Care and Medical Manager Department Quality, Safety and Innovation, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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Piasecki RJ, Himmelfarb CRD, Gleason KT, Justice RM, Hunt EA. The associations between rapid response systems and their components with patient outcomes: A scoping review. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2023; 5:100134. [PMID: 38125770 PMCID: PMC10732356 DOI: 10.1016/j.ijnsa.2023.100134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Background While rapid response systems have been widely implemented, their impact on patient outcomes remains unclear. Further understanding of their components-including medical emergency team triggers, medical emergency team member composition, additional roles in patient care beyond responding to medical emergency team events, and their involvement in "Do-Not-Resuscitate" order placement-may elucidate the relationship between rapid response systems and outcomes. Objective To explore how recent studies have examined rapid response system components in the context of relevant adverse patient outcomes, such as in-hospital cardiac arrests and hospital mortality. Design Scoping review. Methods PubMed, CINAHL, and Embase were searched for articles published between November 2014 and June 2022. Studies mainly focused on rapid response systems and associations with in-hospital cardiac arrests were considered. The following were extracted for analysis: study design, location, sample size, participant characteristics, system characteristics (including medical emergency team member composition, additional system roles outside of medical emergency team events), medical emergency team triggers, in-hospital cardiac arrests, and hospital mortality. Results Thirty-four studies met inclusion criteria. While most studies described triggers used, few analyzed medical emergency team trigger associations with outcomes. Of those, medical emergency team triggers relating to respiratory abnormalities and use of multiple triggers to activate the medical emergency team were associated with adverse patient outcomes. Many studies described medical emergency team member composition, but the way composition was reported varied across studies. Of the seven studies with dedicated medical emergency team members, six found their systems were associated with decreased incidence of in-hospital cardiac arrests. Six of seven studies that described additional medical emergency team roles in educating staff in rapid response system use found their systems were associated with significant decreases in adverse patient outcomes. Four of five studies that described proactive rounding responsibilities reported found their systems were associated with significant decreases in adverse patient outcomes. Reporting of rapid response system involvement in "Do-Not-Resuscitate" order placement was variable across studies. Conclusions Inconsistencies in describing rapid response system components and related data and outcomes highlights how these systems are complex to a degree not fully captured in existing literature. Further large-scale examination of these components across institutions is warranted. Development and use of robust and standardized metrics to track data related to rapid response system components and related outcomes are needed to optimize these systems and improve patient outcomes.
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Affiliation(s)
- Rebecca J. Piasecki
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
| | | | - Kelly T. Gleason
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
| | | | - Elizabeth A. Hunt
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
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18
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Gupta PB, Lighthall G, Htet N. Use of Point-of-Care Ultrasound by Intensive Care Unit Triage Teams in Evaluating Unstable Patients Outside Intensive Care Units. Cureus 2023; 15:e49114. [PMID: 38125228 PMCID: PMC10732337 DOI: 10.7759/cureus.49114] [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: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction Point-of-care ultrasound (POCUS) has become an integral asset in intensive care units (ICUs). However, there is limited literature on the value of POCUS in evaluating deteriorating patients outside the ICU. In this study, we sought to investigate the use and impact of POCUS by ICU triage teams in hospitals outside of the ICU setting. Methods ICU triage fellows were provided a portable ultrasound to use as part of their evaluations during consultations and hospital code activations. Fellows were asked to fill out a survey on how ultrasound was used and its impact on patient management. Free-text data such as reason for ultrasound use, views obtained, clinical impressions before and after ultrasound, and clinical actions were recorded. These data were transcribed and categorized electronically. Results A total of 51 total resuscitations were documented. The most common reason for ICU triage team evaluation was hypotension (53%, N=27). The most common clinical focus for ultrasound use was cardiac assessment (53%, N=27), followed by volume status assessment (35%, N=18). The most common ultrasound views per encounter obtained were parasternal long (82%, N=42), followed by apical four-chamber view (76%, N=39) and subcostal view (75%, N=38). Out of 38 encounters with clinical impressions documented, 79% (N=30) of pre-ultrasound clinical impressions were confirmed by ultrasound use. Of total encounters, 35% (N=18) had a significant clinical action taken based on ultrasound findings (fluid resuscitation, vasopressor initiation, etc.). Conclusions Ultrasound is a valuable tool for patient evaluation in non-ICU wards, especially in confirming clinical impressions and guiding therapeutic actions. Some limitations of this study include reporting bias and incomplete capture of ultrasound use in non-ICU wards.
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Affiliation(s)
- Pranjal B Gupta
- Department of Emergency Medicine, Stanford University, Palo Alto, USA
| | - Geoffrey Lighthall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, USA
- Department of Anesthesia, Veterans Affairs Medical Center, Palo Alto, USA
| | - Natalie Htet
- Department of Emergency Medicine, Stanford University, Palo Alto, USA
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Chua WL, Wee LPC, Lim JYG, Yeo MLK, Jones D, Tan CK, Khan FA, Liaw SY. Automated rapid response system activation-Impact on nurses' attitudes and perceptions towards recognising and responding to clinical deterioration: Mixed-methods study. J Clin Nurs 2023; 32:6322-6338. [PMID: 37087695 DOI: 10.1111/jocn.16734] [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: 09/27/2022] [Revised: 02/12/2023] [Accepted: 04/05/2023] [Indexed: 04/24/2023]
Abstract
AIM To explore general ward nurses' attitudes and perceptions towards recognising and responding to clinical deterioration in a hospital with automated rapid response system activation. BACKGROUND There is growing interest in deploying automated clinical deterioration notification systems to reduce delayed or failed recognition and response to clinical deterioration of ward patients. However, little is known about its impact on ward nurses' perspectives and work patterns. DESIGN A mixed-methods study. METHODS Online survey of 168 registered nurses and individual interviews with 10 registered nurses in one acute hospital in Singapore. The study adhered to the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies. RESULTS Many nurses (38.1%) rarely performed patient assessments or observations other than vital signs assessment to assess for early signs of clinical deterioration. About 30% were worried about being criticised for calling the primary team doctors. Four themes emerged from the qualitative analysis: automated rapid response system activation as a safety net, being more cautious with vital signs monitoring, the NEWS2 alone is inadequate, and ward nurses as the 'middleman' between the intensive care unit outreach nurse and primary team doctors. CONCLUSIONS Although nurses value the automated rapid response system activation as a safety net to minimise delays in accessing urgent critical care resources, it does not address the sociocultural barriers inherent in escalation of care. Although the automated system led nurses to be more cautious with vital signs monitoring, it does not encourage them to perform comprehensive patient assessments to detect early signs of deterioration. RELEVANCE TO CLINICAL PRACTICE Nurse education on assessing for clinical deterioration should focus on the use of broader patient assessment skills other than vital signs. Sociocultural barriers to escalation of care remain a key issue that needs to be addressed by hospital management. NO PATIENT OR PUBLIC CONTRIBUTION No patients, service users, care-givers or members of the public were involved in the study.
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Affiliation(s)
- Wei Ling Chua
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Li-Phing Clarice Wee
- Department of Nursing Administration, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Jia Ying Germaine Lim
- Department of Nursing, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Min Li Kimberly Yeo
- Department of Nursing, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Daryl Jones
- Intensive Care Unit, Austin Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Faheem Ahmed Khan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Sok Ying Liaw
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Hong JQY, Chua WL, Smith D, Huang CM, Goh QLP, Liaw SY. Collaborative practice among general ward staff on escalating care in clinical deterioration: A systematic review. J Clin Nurs 2023; 32:6165-6178. [PMID: 37154497 DOI: 10.1111/jocn.16743] [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] [Received: 11/22/2022] [Revised: 03/30/2023] [Accepted: 04/20/2023] [Indexed: 05/10/2023]
Abstract
AIM To understand the issues surrounding collaborative practice and collaboration experiences among general ward staff in the escalation of care for clinically deteriorating patients. DESIGN A systematic synthesis without meta-analysis. REVIEW METHODS Seven electronic databases (CINAHL, Cochrane, Embase, PsycINFO, PubMed, Scopus and ProQuest Theses and Dissertations) were searched from their inception to 30 April 2022. Two reviewers independently screened titles, abstracts and full text for eligibility. The critical appraisal skill programme, Joanna Briggs Institute checklist for analytical cross-sectional studies and mixed methods appraisal tool were used to appraise the quality of the included studies. Both quantitative and qualitative research data were extracted, analysed and then synthesised using the data-based convergent qualitative synthesis approach. This review adhered to the Synthesis without meta-analysis (SWiM) reporting guidelines. RESULTS A total of 17 studies were included. Two themes and six sub-themes were generated: (1) intraprofessional factors-inadequate handover, workload and mutual support, raising and acting on concerns, and seeking help from seniors and (2) interprofessional factors-differences in communication styles, and hierarchical approach versus interpersonal relationships. CONCLUSIONS This systematic review highlights the need to address the intra- and interprofessional issues surrounding collaborative practice in escalation of care among general ward staff. IMPLICATIONS FOR THE PROFESSION Findings from this review will inform healthcare leaders and educators on the development of relevant strategies and multi-disciplinary training to foster effective teamwork among nurses and doctors, with the goal of improving the escalation of care for patients with clinical deterioration. NO PATIENT OR PUBLIC CONTRIBUTION This systematic review did not directly involve patient or public contribution to the manuscript.
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Affiliation(s)
- Jordan Qi Yang Hong
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wei Ling Chua
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Duncan Smith
- Department of Nursing, School of Health and Psychological Sciences, City University of London, London, UK
- Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals, NHS Foundation Trust, London, UK
| | - Chi Ming Huang
- Nursing Service, National Healthcare Group, Tan Tock Seng Hospital, Singapore, Singapore
| | - Qin Ling Pearlyn Goh
- Department of Nursing, National Healthcare Group, Khoo Teck Puat Hospital, Yishun Health Campus, Singapore, Singapore
| | - Sok Ying Liaw
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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21
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Liu M, Whittam S, Thornton A, Goncharov L, Slade D, McElduff B, Kelly P, Law CK, Walsh S, Pollnow V, Cuffe J, McMahon J, Aggar C, Bilo J, Bowen K, Chow JSF, Duffy K, Everett B, Ferguson C, Frost SA, Gleeson N, Hackett K, Komusanac I, Marshall S, May S, McErlean G, Melbourne G, Murphy J, Newbury J, Newman D, Rihari-Thomas J, Sciuriaga H, Sturgess L, Taylor J, Tuqiri K, McInnes E, Middleton S. The ACCELERATE Plus (assessment and communication excellence for safe patient outcomes) Trial Protocol: a stepped-wedge cluster randomised trial, cost-benefit analysis, and process evaluation. BMC Nurs 2023; 22:275. [PMID: 37605224 PMCID: PMC10440862 DOI: 10.1186/s12912-023-01439-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Nurses play an essential role in patient safety. Inadequate nursing physical assessment and communication in handover practices are associated with increased patient deterioration, falls and pressure injuries. Despite internationally implemented rapid response systems, falls and pressure injury reduction strategies, and recommendations to conduct clinical handovers at patients' bedside, adverse events persist. This trial aims to evaluate the effectiveness, implementation, and cost-benefit of an externally facilitated, nurse-led intervention delivered at the ward level for core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication. We hypothesise the trial will reduce medical emergency team calls, unplanned intensive care unit admissions, falls and pressure injuries. METHODS A stepped-wedge cluster randomised trial will be conducted over 52 weeks. The intervention consists of a nursing core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication and will be implemented in 24 wards across eight hospitals. The intervention will use theoretically informed implementation strategies for changing clinician behaviour, consisting of: nursing executive site engagement; a train-the-trainer model for cascading facilitation; embedded site leads; nursing unit manager leadership training; nursing and medical ward-level clinical champions; ward nurses' education workshops; intervention tailoring; and reminders. The primary outcome will be a composite measure of medical emergency team calls (rapid response calls and 'Code Blue' calls), unplanned intensive care unit admissions, in-hospital falls and hospital-acquired pressure injuries; these measures individually will also form secondary outcomes. Other secondary outcomes are: i) patient-reported experience measures of receiving safe and patient-centred care, ii) nurses' perceptions of barriers to physical assessment, readiness to change, and staff engagement, and iii) nurses' and medical officers' perceptions of safety culture and interprofessional collaboration. Primary outcome data will be collected for the trial duration, and secondary outcome surveys will be collected prior to each step and at trial conclusion. A cost-benefit analysis and post-trial process evaluation will also be undertaken. DISCUSSION If effective, this intervention has the potential to improve nursing care, reduce patient harm and improve patient outcomes. The evidence-based implementation strategy has been designed to be embedded within existing hospital workforces; if cost-effective, it will be readily translatable to other hospitals nationally. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ID: ACTRN12622000155796. Date registered: 31/01/2022.
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Grants
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- 1196352 National Health and Medical Research Council Investigator Leadership Grant
- New South Wales Nursing and Midwifery Strategy Reserve Fund
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Affiliation(s)
- Mark Liu
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 40 Edward Street, North Sydney, NSW, 2060, Australia
| | - Susan Whittam
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- St Vincent's Health Network Sydney, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
| | - Anna Thornton
- St Vincent's Health Network Sydney, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
| | - Liza Goncharov
- Institute for Communication in Healthcare, Australian National University, Baldessin Precinct Building, 110 Ellery Crescent, Acton, ACT, 2601, Australia
| | - Diana Slade
- Institute for Communication in Healthcare, Australian National University, Baldessin Precinct Building, 110 Ellery Crescent, Acton, ACT, 2601, Australia
| | - Benjamin McElduff
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 40 Edward Street, North Sydney, NSW, 2060, Australia
| | - Patrick Kelly
- School of Public Health, University of Sydney, Edward Ford Building, A27 Fisher Road, Camperdown, NSW, 2006, Australia
| | - Chi Kin Law
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Medical Foundation Building, 92-94 Parramatta Road, Camperdown, NSW, 2050, Australia
| | - Sarah Walsh
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- St Vincent's Health Network Sydney, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
| | - Vivien Pollnow
- St Vincent's Health Network Sydney, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
| | - Jayde Cuffe
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Jake McMahon
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Christina Aggar
- Southern Cross University, Military Road, East Lismore, NSW, 2480, Australia
- Northern NSW Local Health District, Crawford House, Hunter Street, Lismore, NSW, 2480, Australia
| | - Jacqueline Bilo
- St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Karen Bowen
- Northern NSW Local Health District, Crawford House, Hunter Street, Lismore, NSW, 2480, Australia
| | - Josephine S F Chow
- South Western Sydney Local Health District, Liverpool Hospital Eastern Campus, Corner of Lachlan and Hart Streets, Liverpool, NSW, 2170, Australia
- Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW, 2170, Australia
| | - Katharine Duffy
- Northern NSW Local Health District, Crawford House, Hunter Street, Lismore, NSW, 2480, Australia
| | - Bronwyn Everett
- University of Wollongong, Northfields Avenue, Wollongong, NSW, 2522, Australia
| | - Caleb Ferguson
- University of Wollongong, Northfields Avenue, Wollongong, NSW, 2522, Australia
| | - Steven A Frost
- South Western Sydney Local Health District, Liverpool Hospital Eastern Campus, Corner of Lachlan and Hart Streets, Liverpool, NSW, 2170, Australia
- University of Wollongong, Northfields Avenue, Wollongong, NSW, 2522, Australia
| | - Narelle Gleeson
- Lismore Base Hospital, 60 Uralba Street, Lismore, NSW, 2480, Australia
| | - Kate Hackett
- South Eastern Sydney Local Health District, The Sutherland Hospital and Community Health Service, Corner The Kingsway and Kareena Road, Caringbah, NSW, 2229, Australia
| | - Ivanka Komusanac
- Sydney Local Health District, King George V Building, Missenden Road, Camperdown, NSW, 2050, Australia
| | - Sonia Marshall
- South Western Sydney Local Health District, Liverpool Hospital Eastern Campus, Corner of Lachlan and Hart Streets, Liverpool, NSW, 2170, Australia
| | - Sharon May
- Fairfield Hospital, Polding Street and Prairie Vale Road, Prairiewood, NSW, 2176, Australia
| | - Gemma McErlean
- University of Wollongong, Northfields Avenue, Wollongong, NSW, 2522, Australia
| | - Gregory Melbourne
- South Western Sydney Local Health District, Liverpool Hospital Eastern Campus, Corner of Lachlan and Hart Streets, Liverpool, NSW, 2170, Australia
| | - Jade Murphy
- St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Joanne Newbury
- The Sutherland Hospital, Corner The Kingsway and Kareena Road, Caringbah, NSW, 2229, Australia
| | - Deb Newman
- Lismore Base Hospital, 60 Uralba Street, Lismore, NSW, 2480, Australia
| | - John Rihari-Thomas
- University of Wollongong, Northfields Avenue, Wollongong, NSW, 2522, Australia
| | - Hayley Sciuriaga
- Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Lauren Sturgess
- St George Hospital, Gray Street, Kogarah, NSW, 2217, Australia
| | - Joanne Taylor
- St Vincent's Health Network Sydney, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
| | - Karen Tuqiri
- Prince of Wales Hospital, 320-346 Barker Street, Randwick, NSW, 2031, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 40 Edward Street, North Sydney, NSW, 2060, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia.
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 40 Edward Street, North Sydney, NSW, 2060, Australia.
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22
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Ko JP, Ng LS, Goh KJ, Chai HZ, Phua GC, Tan QL. Staff perception and attitudes towards a medical rapid response team with a multi-tiered response. Singapore Med J 2023; 64:527-533. [PMID: 34911185 PMCID: PMC10476913 DOI: 10.11622/smedj.2021223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 06/14/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Joanna Phone Ko
- Speciality Nursing, Nursing Division, Singapore General Hospital, Singapore
| | - Lit Soo Ng
- Speciality Nursing, Nursing Division, Singapore General Hospital, Singapore
| | - Ken Junyang Goh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Hui Zhong Chai
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Ghee Chee Phua
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Qiao Li Tan
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
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23
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Basic D, Ní Chróinín D. In-hospital outcomes among older medical inpatients admitted to aged care wards after activation of a 2-tier rapid response system. BMC Geriatr 2023; 23:425. [PMID: 37434113 DOI: 10.1186/s12877-023-03947-6] [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: 07/06/2022] [Accepted: 03/31/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND The outcomes of rapid response systems (RRS) are poorly established in older people. We examined the outcomes in older inpatients at a tertiary hospital that uses a 2-tier RRS, including the outcomes of each tier. METHODS The 2-tier RRS comprised the clinical review call (CRC) (tier one) and the medical emergency team call (MET) (tier two). We compared the outcomes in four configurations of MET and CRC (MET with CRC; MET without CRC; CRC without MET; neither MET nor CRC). The primary outcome was in-hospital death, and secondary outcomes were length of stay (LOS) and new residential facility placement. Statistical analyses were carried out using Fisher's exact tests, Kruskal-Wallis tests, and logistic regression. RESULTS A total of 433 METs and 1,395 CRCs occurred among 3,910 consecutive admissions of mean age 84 years. The effect of a MET on death was unaffected by the occurrence of a CRC. The rates of death for MET ± CRC, and CRC without MET, were 30.5% and 18.5%, respectively. Patients having one or more MET ± CRC (adjusted odds ratio [aOR] 4.04, 95% confidence interval [CI] 2.96-5.52), and those having one or more CRC without MET (aOR 2.22, 95% CI 1.68-2.93), were more likely to die in adjusted analysis. Patients who required a MET ± CRC were more likely to be placed in a high-care residential facility (aOR 1.52, 95% CI 1.03-2.24), as were patients who required a CRC without MET (aOR 1.61, 95% CI 1.22-2.14). The LOS of patients who required a MET ± CRC, and CRC without MET, was longer than that of patients who required neither (P < 0.001). CONCLUSIONS Both MET and CRC were associated with increased likelihood of death and new residential facility placement, after adjusting for factors such as age, comorbidity, and frailty. These data are important for patient prognostication, discussions on goals of care, and discharge planning. The high death rate of patients requiring a CRC (without a MET) has not been previously reported, and may suggest that CRCs among older inpatients should be expediated and attended by senior medical personnel.
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Affiliation(s)
- David Basic
- Department of Geriatric Medicine, Liverpool Hospital, Locked Mail Bag 7103, Liverpool BC, NSW, 1871, Australia.
| | - Danielle Ní Chróinín
- Department of Geriatric Medicine, Liverpool Hospital, and South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
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24
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Shukairy MK, Chadwick L, LaPorte CM, Pudwill J, Syslo JA, Fitzgerald J, Bier-Laning CM. Implementing an Interprofessional Difficult Airway Response Team to Identify and Manage High-Risk Airways. Otolaryngol Head Neck Surg 2023. [PMID: 37130509 DOI: 10.1002/ohn.357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/16/2023] [Accepted: 04/01/2023] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To describe a multidisciplinary approach to and results from the creation of a difficult airway response team (DART) to address the management of inpatient loss of airway events. METHODS Description of an interprofessional process to establish and sustain a DART program at a tertiary care hospital. An Institutional Review Board-approved retrospective review of the quantitative results was conducted from November 2019 through March 2021. RESULTS After establishing the existing processes for difficult airway management, a focus on "work as imagined" identified 4 pillars to address the goal for the project of bringing the right providers with the right equipment to the right patients at the right time through DART equipment carts, an expanded DART code team, a screening tool to identify patients with at-risk airways and unique messaging for DART code alerts. "Work as done" was assessed through simulations. Educational efforts included further simulations and group teaching. Sustainability was achieved through ongoing e-learning and bidirectional feedback. During the period of study, there were 40,752 patients admitted and 28,013 (69%) screens completed. At-risk airways were identified in 4282 admissions (11%), most commonly due to a history of a difficult airway (19%) and elevated body mass index (16%). The DART responded to 126 codes. There were no airway-related deaths or serious adverse events. DISCUSSION A successful DART program was created, optimized, and sustained using components of interprofessional meetings, simulation, bidirectional feedback, and quantitative analysis. IMPLICATIONS FOR PRACTICE The techniques described can serve to guide groups who identify a quality improvement project that involves interactions between multiple stakeholders.
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Affiliation(s)
| | - Lexia Chadwick
- Department of Anesthesiology, University of Illinois, Chicago, Illinois, USA
| | - Cinthia M LaPorte
- Department of Nursing, Loyola University Medical Center, Maywood, Illinois, USA
| | - Josephine Pudwill
- Department of Nursing, Loyola University Medical Center, Maywood, Illinois, USA
| | - Jennifer A Syslo
- Office of Patient Safety, Loyola University Medical Center, Maywood, Illinois, USA
| | - Julie Fitzgerald
- Department of Pediatrics, Ronald McDonald's Children's Hospital, Loyola University Medical Center, Maywood, Illinois, USA
| | - Carol M Bier-Laning
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, USA
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25
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Jamous SE, Kouatly I, Irani J, Badr LK. Implementing a Rapid Response Team: A Quality Improvement Project in a Low- to Middle-Income Country. Dimens Crit Care Nurs 2023; 42:171-178. [PMID: 36996363 DOI: 10.1097/dcc.0000000000000584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND The benefits of rapid response teams (RRTs) have been controversial with few studies conducted in low- to middle-income countries. OBJECTIVE The aim of this study was to investigate the effectiveness of implementing an RRT on 4 patient outcomes. METHODS We conducted a quality improvement pre-and-post design using the Plan-Do-Study-Act model in a tertiary hospital in a low- to middle-income country. We collected data before and after implementing the RRT in 4 phases and over 4 years. RESULTS Survival to discharge after cardiac arrest was 25.0% per 1000 discharges in 2016 and increased to 50% in 2019, a 50% increase. The rate of activations per 1000 discharges was 20.45% for the code team in 2016 and 33.6% for the RRT team in 2019. Thirty-one patients who arrested were transferred to a critical care unit before implementing the RRT, and 33% of such patients were transferred after. The time it took the code team to arrive at the bedside was 3.1 minutes in 2016 and decreased to 1.7 minutes for the RRT team to arrive in 2019, a 46% decrease. DISCUSSION AND CLINICAL IMPLICATIONS Implementing an RTT led by nurses in a low- to middle-income country increased the survival rate of patients who had a cardiac arrest by 50%. The role of nurses in improving patient outcomes and saving lives is substantial and empowers nurses to call for assistance to save patient lives who show early signs of a cardiac arrest. Hospital administrators should continue to use strategies to improve nurses' timely response to the clinical deterioration of patients and to continue to collect data to assess the effect of the RRT over time.
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26
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Satyavolu R, Ruknuddeen MI, Soar N, Edwards SM. Dosage and clinical outcomes of medical emergency team and conventional referral mediated unplanned intensive care admissions. J Intensive Care Soc 2023; 24:178-185. [PMID: 37260436 PMCID: PMC10227895 DOI: 10.1177/17511437211060157] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
Background: Unplanned intensive care unit (ICU) admission occurs via activation of medical emergency team (MET) and conventional ICU referral (CIR), i.e., ICU consultation. We aimed to compare the dosage, association with unplanned ICU admissions and hospital mortality between MET and CIR systems. Methods: We performed a retrospective, single centre observational study on unplanned ICU admissions from hospital wards between July 2017 and June 2018. We evaluated the dosage (expressed per 1000 admissions) and association of CIR and MET system with unplanned ICU admission using Chi-square test. The relationship (unadjusted and adjusted to Australia and New Zealand risk of death (ANZROD) and lead time) between unplanned ICU admission pathway (MET vs CIR) and hospital mortality was tested by binary logistic regression analysis [Odds ratio (OR) with 95% confidence interval (CI)]. Results: Out of 38,628 patients hospitalised, 679 had unplanned ICU admission (2%) with an ICU admission rate of 18 per 1000 ward admissions. There were 2153 MET and 453 CIR activations, producing a dosage of 56 and 12 per 1000 admissions, respectively. Higher unplanned ICU admission was significantly associated with CIR compared to MET activation (324/453 (71.5%) vs 355/2153 (16.5%) p < 0.001). On binary logistic regression, MET system was significantly associated with higher hospital mortality on unadjusted analysis (OR 1.65 (95% CI: 1.09-2.48) p = 0.02) but not after adjustment with ANZROD and lead time (OR 1.15 (95% CI: 0.71-1.86), p = 0.58). Conclusions: Compared to CIR, MET system had higher dosage but lower frequency of unplanned ICU admissions and lacked independent association with hospital mortality.
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Affiliation(s)
| | | | - Natalie Soar
- Intensive Care Unit, Lyell Mc Ewin Hospital, Elizabeth Vale, Australia
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27
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Felix HM, Paulson MR, Garcia JP, Dugani SB, Torres-Guzman RA, Avila FR, Maita K, Forte AJ, Maniaci MJ. Avoiding Escalation to the Emergency Department by Activating an In-Home Rapid Response Team in the 30 Days After Hospital-at-Home Discharge. J Emerg Med 2023; 64:455-463. [PMID: 37002160 PMCID: PMC10133039 DOI: 10.1016/j.jemermed.2023.02.023] [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: 11/08/2022] [Revised: 02/07/2023] [Accepted: 02/17/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Mayo Clinic's virtual hybrid hospital-at-home program, Advanced Care at Home (ACH) monitors acute and post-acute patients for signs of deterioration and institutes a rapid response (RR) system if detected. OBJECTIVE This study aimed to describe Mayo Clinic's ACH RR team and its effect on emergency department (ED) use and readmission rates. METHODS This was a retrospective review of all post-inpatient (restorative phase) ACH patients admitted from July 6, 2020 through June 30, 2021. If the restorative patient had a clinical decompensation, an RR was activated. All RR activations were analyzed for patient demographic characteristics, admitting and escalation diagnosis, time spent by virtual team on the RR, and whether the RR resulted in transport to the ED or hospital readmission. RESULTS Three hundred and twenty patients were admitted to ACH during the study interval; 230 received restorative care. Seventy-two patients (31.3%) had events that triggered an RR. Fifty (69.4%) of the RR events were related to the admission diagnosis (p < 0.001; 95% CI 0.59-0.80). Twelve patients (16.7%) required transport to an ED for further treatment and were readmitted and 60 patients (83.3%) were able to be treated successfully in the home by the RR team (p < 0.001; 95% CI 0.08-0.25). CONCLUSIONS The use of an ACH RR team was effective at limiting both escalations back to an ED and hospital readmissions, as 83% of deteriorating patients were successfully stabilized and managed in their homes. Implementing a hospital-at-home RR team can reduce the need for ED use by providing critical resources and carrying out required interventions to stabilize the patient's condition.
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Affiliation(s)
- Heidi M Felix
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - Margaret R Paulson
- Division of Hospital Internal Medicine, Mayo Clinic Health Systems, Eau Claire, Wisconsin
| | - John P Garcia
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Sagar B Dugani
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Karla Maita
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Michael J Maniaci
- Division of Hospital Internal Medicine, Mayo Clinic, Jacksonville, Florida
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28
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Feroz Ali N, Amir A, Punjwani A, Bhimani R. Rapid Response Team Activation Triggers in Adults and Children: An Integrative Review. Rehabil Nurs 2023; 48:96-108. [PMID: 36941241 DOI: 10.1097/rnj.0000000000000408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
PURPOSE This integrative review aims to identify the triggers for rapid response team (RRT) activation and their outcomes in pediatric patients and to compare them with those of adult patients. In addition, this integrative review synthesizes the outcomes of cardiopulmonary resuscitation (CPR), intensive care unit (ICU) admission, length of hospital stay, and mortality following RRT activation. METHOD An integrative review using the Whittemore and Knafl methodology was undertaken with a search of three large databases (PubMed, Ovid MEDLINE, and CINAHL) and found 25 relevant studies published in the years 2017 through 2022. RESULTS Tachypnea, decreased oxygen saturation, tachycardia, changes in blood pressure, and level of consciousness were the most common triggers in both populations. However, specific activation triggers differed between children and adults. CONCLUSIONS The most common triggers for RRT are detectable through vital signs monitoring; therefore, vigilant tracking of patients' vital signs is critical and can provide early clues to clinical deterioration.
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Affiliation(s)
| | - Asma Amir
- Aga Khan University, Karachi, Pakistan
| | | | - Rozina Bhimani
- University of Minnesota School of Nursing, Minneapolis, MN, USA
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29
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Critical care outreach teams: a service without walls. Intensive Care Med 2023; 49:572-574. [PMID: 36922404 DOI: 10.1007/s00134-023-07021-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 02/25/2023] [Indexed: 03/17/2023]
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30
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The patient experience of a medical emergency team review: A convergent mixed-methods study. Aust Crit Care 2023; 36:254-261. [PMID: 35177341 DOI: 10.1016/j.aucc.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/21/2021] [Accepted: 12/21/2021] [Indexed: 11/23/2022] Open
Abstract
AIMS The aim of this study was to explore clinician-patient engagement during, and patient experience of, medical emergency team (MET) reviews. DESIGN This study involved a convergent mixed-methods design. METHODS This three-phase study was conducted at two hospitals of one Australian health service. Reviews by the MET were observed for clinician-patient engagement behaviours; medical records were audited to confirm patient demographics and clinical characteristics; and patients who received a MET review were interviewed. Quantitative data were analysed using descriptive statistics, and thematic analysis of qualitative interview data was conducted. RESULTS In total, 26 MET reviews were observed for 22 patients (median age = 81.5 years and 68.2% females). Between 8 and 13 clinicians and other staff members were present during each review, with a total of 209 clinicians present during the 26 reviews. Clinicians were not observed to speak directly or indirectly to the patient about their care in 38.5% (n = 10/26) of the MET reviews, and 58.3% (n = 56/96) of interventions were performed without explanation. Four themes were identified from the interviews: An unexpected event; A lack of understanding; In good hands, and What happens next? CONCLUSION Clinician-patient engagement was infrequent during and after MET reviews. Patients experienced surprise from the sudden arrival of clinicians in their room and had poor levels of understanding about the review. However, most patients felt supported and safe. MET reviews are frequent safety-critical events, and this study identified the patient experience of these events. Clinicians should be aware that patients expressed they were surprised and shocked by the review and that an explanation of what was being done by the clinical team was rarely offered. These findings can be used to inform strategies to improve their patient-engagement behaviours and patient-centred care.
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31
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Tan SC, Ma H, Hart GK, Holdsworth M. Rapid response teams: A review of data collection practice in Victoria, Australia. Aust Crit Care 2023; 36:269-273. [PMID: 35058119 DOI: 10.1016/j.aucc.2021.12.001] [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: 11/18/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Successful implementation of rapid response teams (RRTs) requires robust data collection and reporting processes. However, there is variation in data collection practice in RRT activity between hospitals, leading to difficulties in quality review, collaboration and research. Although a standardised RRT data collection model would be a key step in addressing this, there is uncertainty regarding existing RRT data collection practice across Victoria. OBJECTIVES This study was endorsed by Safer Care Victoria (SCV) to evaluate existing RRT data collection practice across Victoria. METHODOLOGY Between 2016 and 2017, hospitals in Victoria were surveyed on data collection practice for RRT activity. Data collected included the fields populated and the mode of data collection. Qualitative content analysis, utilising a blend of pre-existing frameworks and ground-up data-driven approaches for derivation of a coding frame, was used to identify common categories. Validation of the analysis and results was performed by consultation with stakeholder groups. RESULTS Twenty five hospitals across 18 health networks contributed data, with a mix of tertiary (9/25), metropolitan (11/25) and rural (5/25) hospitals. Seven hospitals collected data electronically, the remainder using paper with abstraction to electronic spreadsheets. None of the hospitals linked with existing hospital data systems to reduce manual data entry requirements. Dataset size varied from 16 to 97 variables but demonstrated content consistency and could be mapped onto seven key categories (comprising antecedent, afferent, event, post-event, audit, context and patient data). Within each category, there was substantial variation in terminology and variable values, but consistency in the collection of a certain subset of variables. CONCLUSION Despite broad variation in data collection practice, existing datasets can be readily mapped into seven key categories, with the consistent collection of a subset of variables within each category. These variables could inform the development of a minimum dataset within a standardised RRT reporting framework and accommodate data submission from hospitals of differing resource bases.
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Affiliation(s)
- Sing Chee Tan
- Department of Intensive Care Medicine, Northern Health, 185 Cooper St., Epping 3076, VIC, Australia; Department of Intensive Care Medicine, Austin Health, 145 Studley Rd., Heidelberg, 3084, VIC, Australia; Centre for Digital Transformation of Health, University of Melbourne, Parkville, 3000, VIC, Australia.
| | - Hongyung Ma
- Centre for Digital Transformation of Health, University of Melbourne, Parkville, 3000, VIC, Australia
| | - Graeme K Hart
- Department of Intensive Care Medicine, Austin Health, 145 Studley Rd., Heidelberg, 3084, VIC, Australia; Centre for Digital Transformation of Health, University of Melbourne, Parkville, 3000, VIC, Australia; Critical Care Clinical Network, Safer Care Victoria, 150 Lonsdale St., Melbourne, 3000, VIC, Australia
| | - Monica Holdsworth
- Critical Care Clinical Network, Safer Care Victoria, 150 Lonsdale St., Melbourne, 3000, VIC, Australia
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32
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Piasecki RJ, Hunt EA, Perrin N, Spaulding EM, Winters B, Samuel L, Davidson PM, Strobos NC, Churpek M, Himmelfarb CR. Using rapid response system trigger clusters to characterize patterns of clinical deterioration among hospitalized adult patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.06.23285560. [PMID: 36798369 PMCID: PMC9934794 DOI: 10.1101/2023.02.06.23285560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Background Many rapid response system (RRS) events are activated using multiple triggers. However, the patterns in which RRS triggers co-occur to activate the medical emergency team (MET) to respond to RRS events is unknown. The purpose of this study was to identify and describe the patterns (RRS trigger clusters) in which RRS triggers co-occur when used to activate the MET and determine the association of these clusters with outcomes using a sample of hospitalized adult patients. Methods RRS events among adult patients from January 2015 to December 2019 in the Get With The Guidelines- Resuscitation registry's MET module were examined (n=134,406). A combination of cluster analyses methods was performed to group patients into RRS trigger clusters based on the triggers used to activate their RRS events. Pearson's chi-squared and ANOVA tests were used to examine differences in patient characteristics across RRS trigger clusters. Multilevel logistic regression was used to examine the associations between RRS trigger clusters and outcomes following RRS events. Results Six RRS trigger clusters were identified in the study sample. The RRS triggers that predominantly identified each cluster were as follows: tachypnea, new onset difficulty in breathing, and decreased oxygen saturation (Cluster 1); tachypnea, decreased oxygen saturation, and staff concern (Cluster 2); respiratory depression, decreased oxygen saturation, and mental status changes (Cluster 3); tachycardia and staff concern (Cluster 4); mental status changes (Cluster 5); hypotension and staff concern (Cluster 6). Significant differences in patient characteristics were observed across RRS trigger clusters. Patients in Clusters 3 and 6 were associated with an increased likelihood of in-hospital cardiac arrest (IHCA [p<0.01]), while Cluster 4 was associated with a decreased likelihood of IHCA (p<0.01). All clusters were associated with an increased risk of mortality (p<0.01). Conclusions We discovered six novel RRS trigger clusters with differing relationships to adverse patient outcomes following RRS events. RRS trigger clusters may prove crucial in clarifying the associations between RRS events and adverse outcomes and may aid in clinician decision-making during RRS events.
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Gross CR, Adams DH, Patel P, Varghese R. Failure to Rescue: A Quality Metric for Cardiac Surgery and Cardiovascular Critical Care. Can J Cardiol 2023; 39:487-496. [PMID: 36621563 DOI: 10.1016/j.cjca.2023.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/03/2023] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
Failure to rescue, defined as mortality after a surgical complication, is a widely accepted quality metric across many specialties and is becoming an important metric in cardiac surgery. The failure to rescue metric provides a target for improvements in patient outcomes after complications occur. To be used appropriately, the failure to rescue metric must be defined using a prespecified set of life-threatening and rescuable complications. Successful patient rescue requires a systematic approach of complication recognition, timely escalation of care, effective medical management, and mitigation of additional complications. This process requires contributions from cardiac surgeons, intensivists, and other specialists including cardiologists, neurologists, and anaesthesiologists. Factors that affect failure to rescue rates in cardiac surgery and cardiovascular critical care include nurse staffing ratios, intensivist coverage, advanced specialist support, hospital and surgical volume, the presence of trainees, and patient comorbidities. Strategies to improve patient rescue include working to understand the mechanisms of failure to rescue, anticipating postoperative complications, prioritizing microsystem factors, enhancing early escalation of care, and educating and empowering junior clinicians. When used appropriately, the failure to rescue quality metric can help institutions focus on improving processes of care that minimize morbidity and mortality from rescuable complications after cardiac surgery.
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Affiliation(s)
- Caroline R Gross
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David H Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Parth Patel
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robin Varghese
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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dos Santos PKL, Oliveira GN, Sichieri K, da Cruz DDALM, Nogueira LDS. Features of the triggering of the yellow code and factors associated with the occurrence of adverse events. Rev Bras Enferm 2023; 76:e20220181. [PMID: 36946812 PMCID: PMC10021946 DOI: 10.1590/0034-7167-2022-0181] [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: 05/21/2022] [Accepted: 11/17/2022] [Indexed: 03/22/2023] Open
Abstract
Objective: to analyze the characteristics of the activation of the yellow code in wards and identify the factors associated with adverse events after the Rapid Response Team. Methods: a cross-sectional study with retrospective analysis of medical records of adults admitted to medical or surgical clinic wards of the University Hospital of São Paulo. Results: among the 91 patients, the most frequent signs of triggers (n=107) were peripheral oxygen saturation of less than 90% (40.2%) and hypotension (30.8%). Regarding the associated factors the research identified each minute of attendance of the Rapid Response Team in the wards increased by 1.2% odds of adverse events (twenty-four unplanned admission in the ICU and one cardiac arrest) in the sample (p=0.014). Conclusions: decreased oxygen saturation and hypotension were the main reasons for the triggering, and the length of care was associated with the frequency of adverse events.
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Affiliation(s)
| | | | - Karina Sichieri
- Universidade de São Paulo, Hospital Universitário. São Paulo, São Paulo, Brazil
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Baugh CW, Sodickson AD, Kivlehan SM, Chen PC, Perencevich ML, Jesudian AB. A Novel Multidisciplinary Team Activation for Patients with Severe Gastrointestinal Bleeding: Creation of the Code GI Bleed Protocol. Clin Exp Gastroenterol 2023; 16:55-58. [PMID: 37131985 PMCID: PMC10149094 DOI: 10.2147/ceg.s404247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/18/2023] [Indexed: 05/04/2023] Open
Abstract
Patients with gastrointestinal (GI) bleeding present to the emergency department (ED) with a wide spectrum of illness severity. Among the most critically ill patients, comorbidities and other risk factors, such as liver disease and anticoagulation, can complicate their management. These patients are resource-intensive to stabilize and resuscitate, often requiring the continuous attention of multiple ED staff members along with rapid mobilization of specialty care. At a tertiary care hospital with the ability to provide definitive care for the most critically ill patients with GI bleeding, we introduced a multi-disciplinary team activation pathway to bring together specialists to immediately respond to the ED. We designed a Code GI Bleed pathway to expedite hemodynamic stabilization, diagnostics, source control, and timely disposition out of the ED to the intensive care unit or relevant procedural area of the hospital.
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Affiliation(s)
- Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Correspondence: Christopher W Baugh, Brigham and Women’s Hospital, Department of Emergency Medicine, 75 Francis Street, Neville House 2 Floor, Boston, MA, 02115, USA, Tel +1 617-732-8192, Fax +1 617-264-6848, Email
| | - Aaron D Sodickson
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sean M Kivlehan
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul C Chen
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Molly L Perencevich
- Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Arun B Jesudian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USA
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Santos PKLD, Oliveira GN, Sichieri K, Cruz DDALMD, Nogueira LDS. Características do acionamento do código amarelo e fatores associados à ocorrência de eventos adversos. Rev Bras Enferm 2023. [DOI: 10.1590/0034-7167-2022-0181pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Abstract
RESUMO Objetivo: analisar as características do acionamento do código amarelo em unidades de internação e identificar os fatores associados à ocorrência de eventos adversos após o atendimento do Time de Resposta Rápida. Métodos: estudo transversal com análise retrospectiva de prontuários de adultos internados em enfermarias de Clínica Médica ou Cirúrgica de hospital universitário de São Paulo. Resultados: entre os 91 pacientes, os sinais mais frequentes dos acionamentos (n=107) foram saturação periférica de oxigênio inferior a 90% (40,2%) e hipotensão arterial (30,8%). Quanto aos fatores associados, identificou-se que cada minuto de atendimento do Time de Resposta Rápida nas enfermarias aumentou em 1,2% a chance de ocorrência de eventos adversos (24 internações não planejadas em Unidade de Terapia Intensiva e uma parada cardiorrespiratória) na amostra (p=0,014). Conclusões: queda da saturação de oxigênio e hipotensão arterial foram os principais motivos de acionamento, e o tempo de atendimento foi associado à ocorrência de eventos adversos.
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Williams G, Pirret A, Credland N, Odell M, Raftery C, Smith D, Winterbottom F, Massey D. A practical approach to establishing a critical care outreach service: An expert panel research design. Aust Crit Care 2023; 36:151-158. [PMID: 35341667 DOI: 10.1016/j.aucc.2022.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 12/18/2021] [Accepted: 01/18/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND For over two decades, nurse-led critical care outreach services have improved the recognition, response, and management of deteriorating patients in general hospital wards, yet variation in terms, design, implementation, and evaluation of such services continue. For those establishing a critical care outreach service, these factors make the literature difficult to interpret and translate to the real-world setting. AIM The aim of this study was to provide a practical approach to establishing a critical care outreach service in the hospital setting. METHOD An international expert panel of clinicians, managers, and academics with experience in implementing, developing, operationalising, educating, and evaluating critical care outreach services collaborated to synthesise evidence, experience, and clinical judgment to develop a practical approach for those establishing a critical care outreach service. A rapid review of the literature identified publications relevant to the study. A modified Delphi technique was used to achieve expert panel consensus particularly in areas where insufficient published literature or ambiguities existed. FINDINGS There were 502 publications sourced from the rapid review, of which 104 were relevant and reviewed. Using the modified Delphi technique, the expert panel identified five key components needed to establish a critical care outreach service: (i) approaches to service delivery, (ii) education and training, (iii) organisational engagement, (iv) clinical governance, and (v) monitoring and evaluation. CONCLUSION An expert panel research design successfully synthesised evidence, experience, and clinical judgement to provide a practical approach for those establishing a critical care outreach service. This method of research will likely be valuable in other areas of practice where terms are used interchangeably, and the literature is diverse and lacking a single approach to practice.
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Affiliation(s)
- Ged Williams
- School of Nursing & Midwifery, Griffith University, Australia; South Metropolitan Health Service, Perth, Australia.
| | - Alison Pirret
- Critical Care Complex, Middlemore Hospital, Auckland, New Zealand; Massey University, Auckland, New Zealand
| | - Nicki Credland
- Reader in Critical Care Education, University of Hull, United Kingdom; Chair British Association of Critical Care Nurses (BACCN), United Kingdom
| | - Mandy Odell
- Critical Care, Royal Berkshire Hospital, NHS FT, Reading, United Kingdom
| | - Chris Raftery
- School of Nursing, Queensland University of Technology, Australia; Gold Coast Health, Queensland, Australia
| | - Duncan Smith
- City, University of London, Northampton Square, London, UK; Honorary Charge Nurse - Patient Emergency Response & Resuscitation Team, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Debbie Massey
- Southern Cross University, Australia; Intensive Care Unit John Flynn Hospital, Tugun, Australia
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Majeed J, Chawla S, Bondar E, Chimonas S, Martin SC, O'Sullivan M, Jones D. Rapid Response Team Activations in Oncologic Ambulatory Sites: Characteristics, Interventions, and Outcomes. JCO Oncol Pract 2022; 18:e1961-e1970. [PMID: 36306480 PMCID: PMC9750547 DOI: 10.1200/op.22.00436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/14/2022] [Accepted: 09/13/2022] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Patients with cancer are vulnerable to clinical deterioration. Rapid response teams (RRTs) identify and manage patients with acute changes in clinical status. Although RRTs have been well studied in the hospital setting, there are limited data on patients who require support in the ambulatory or outpatient oncologic settings. Describe baseline characteristics, reasons for activations, interventions, and outcomes of ambulatory oncologic patients receiving RRT activation in a tertiary cancer center. METHODS We conducted a retrospective review of adult (age ≥ 18 years) patients requiring RRT activation at multiple ambulatory sites between July 2020 and June 2021. Demographic and clinical data captured include age, sex, race, ethnicity, do not resuscitate status, vital signs, receipt of active cancer treatment within 30 days, and cancer type. Using Kaplan-Meier survival analysis and multivariable Cox proportion hazard ratio regression models, outcomes of 90-day mortality and hospitalization were assessed. RESULTS There were 322 RRT activations among 427,734 visits to 10 ambulatory sites (0.75 RRTs/1,000 visits). The most frequent reasons were syncope (25.2%), fall (24.5%), and adverse reaction to cancer therapy or intravenous contrast (16.5%). One hundred thirty-seven (42.5%) required transfer to an emergency department, of which 81 (59.1%) required hospital admission. At 90 days, 51 (15.8%) had died, with 44 (86.3%) receiving comfort measures. Kaplan-Meier survival analysis and multivariable Cox proportional hazard ratio regression showed that heart rate > 100 at RRT presentation and hospitalization after a RRT event were significantly associated with 90-day mortality. CONCLUSION Although uncommon, patients with cancer undergoing care at ambulatory sites can suffer acute clinical deterioration needing RRT review. The rates of hospitalization and mortality among such patients are high, suggesting the need for improved end-of-life care.
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Affiliation(s)
- Jibran Majeed
- Advanced Practice Provider, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sanjay Chawla
- Critical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ellen Bondar
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Susan Chimonas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Steven C. Martin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Daryl Jones
- University Melbourne, Victoria, Parkville, Australia
- DEPM Monash University, Victoria, Prahran, Australia
- Austin Department of Intensive Care, Victoria, Heidelberg, Australia
- Critical Care Outreach Austin Hospital, Victoria, Heidelberg, Australia
- International Society of Rapid Response Systems, London, United Kingdom
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Chalam JN, Noble J, DeLaroche AM, Ehrman RR, Cashen K. Characteristics of Adult Rapid Response Events in a Freestanding Children's Hospital. Hosp Pediatr 2022; 12:1058-1065. [PMID: 36377402 DOI: 10.1542/hpeds.2022-006748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To describe nonhospitalized adult rapid response events (adult RREs) in a freestanding children's hospital and examine the relationship between various demographic and clinical factors with the final patient disposition. METHODS We retrospectively reviewed records for nonhospitalized patients ≥18 years of age from events that occurred in a freestanding pediatric hospital between January 2011 through December 2020. We examined the relationship between adult RREs and patient demographic information, medical history, interventions, and patient disposition following an adult RRE. RESULTS Four hundred twenty-nine events met inclusion criteria for analysis. Most events (69%) occurred in females, 49% of events occurred in family members of patients, and 47% occurred on inpatient floor and ICU areas. The most common presenting complaint was syncope or dizziness (36%). Delivery of bad news or grief response was associated with 14% of adult RREs. Overall, 46% (n = 196) of patients were transferred to the pediatric emergency department (ED). Patients requiring acute intervention or with cardiac or neurologic past medical histories were more likely to be transferred to the pediatric ED. Acute advanced cardiac life support interventions were infrequent but, of the patients taken to the pediatric ED, 1 died, and 3 were admitted to the ICU. CONCLUSIONS Adult RREs are common in freestanding children's hospitals and, although rare, some patients required critical care. Expertise in adult critical care management should be available to the rapid response team and additional training for the pediatric rapid response team in caring for adult nonpatients may be warranted.
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Affiliation(s)
- Jennifer N Chalam
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Jennifer Noble
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.,Central Michigan University School of Medicine, Mount Pleasant, Michigan
| | - Amy M DeLaroche
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.,Central Michigan University School of Medicine, Mount Pleasant, Michigan
| | - Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Medical Center, Sinai-Grace Hospital, Detroit, Michigan
| | - Katherine Cashen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University Children's Hospital, Duke University School of Medicine, Durham, North Carolina
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Bunkenborg G, Barfod O'Connell M, Jensen HI, Bucknall T. Balancing responsibilities, rewards and challenges: A qualitative study illuminating the complexity of being a rapid response team nurse. J Clin Nurs 2022; 31:3560-3572. [PMID: 34985170 PMCID: PMC9787103 DOI: 10.1111/jocn.16183] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/26/2021] [Accepted: 12/09/2021] [Indexed: 12/30/2022]
Abstract
AIM AND OBJECTIVE To explore Rapid Response Team nurses' perceptions of what it means being a Rapid Response Team nurse including their perceptions of the collaborative and organisational aspects of the rapid response team (RRT). BACKGROUND For more than 20 years, RRT nurses have been on the frontline of critical situations in acute care hospitals. However, a few studies report nurses' perceptions of their role as RRT nurses, including collaboration with general ward nurses and physicians. This knowledge is important to guide development and adjustment of the RRT to benefit both patients' safety and team members' job satisfaction. DESIGN Qualitative focus group interviews. METHODS A qualitative approach was applied. Throughout 2018 and across three regions and three acute care settings in Denmark, eight focus group interviews were conducted in which 27 RRT nurses participated. Transcribed interviews were analysed using inductive content analysis. Reporting of this study followed the COREQ checklist. RESULTS One overarching theme 'Balancing responsibilities, rewards, and challenges' was derived, comprising six categories: 'Becoming, developing and fulfilling the RRT nurse role', 'Helping patients as the core function of RRT', 'The RRT-call at its best', 'The obvious and the subtle RRT tasks', 'Carrying the burden of the RRT', and 'Organisational benefits and barriers for an optimal RRT'. CONCLUSION Being a RRT nurse is a complex task. Nurses experience professional satisfaction and find it meaningful helping deteriorating patients. The inadequate resources available to train general ward staff how to manage basic clinical tasks are an added stress to nurses. RELEVANCE TO CLINICAL PRACTICE Organisational managers need a better understanding of the necessary staffing requirements to attend patients' needs, train staff and handle the increasing acuity of ward patients. Failure to do so will be detrimental to patient outcomes and compromise RRT nurses' job satisfaction.
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Affiliation(s)
- Gitte Bunkenborg
- Department of Intensive Care and AnaesthesiologyHolbæk HospitalHolbækDenmark,Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark
| | | | - Hanne Irene Jensen
- Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark,Department of Intensive Care and AnaesthesiologyLillebaelt HospitalUniversity Hospital of Southern DenmarkKoldingDenmark
| | - Tracey Bucknall
- Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark,Alfred Health Centre for Quality and Patient Safety ResearchInstitute of Health TransformationDeakin UniversityBurwoodVictoriaAustralia
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Ahmed M, Sarwer F, . G, Jawaid M, Raina S, Alnazeh A. Evaluation of Automated Alert and Activation of Medical Emergency Team in Head and Neck Cancer Patients Using Early Warning Score at Tertiary Level Hospital in North India. Cureus 2022; 14:e31428. [DOI: 10.7759/cureus.31428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/10/2022] [Indexed: 11/15/2022] Open
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Olsen SL, Søreide E, Hansen BS. We Are Not There Yet: A Qualitative System Probing Study of a Hospital Rapid Response System. J Patient Saf 2022; 18:722-729. [PMID: 35384936 PMCID: PMC9524589 DOI: 10.1097/pts.0000000000001000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The capability of a hospital's rapid response system (RRS) depends on various factors to reduce in-hospital cardiac arrests and mortality. Through system probing, this qualitative study targeted a more comprehensive understanding of how healthcare professionals manage the complexities of RRS in daily practice as well as identifying its challenges. METHODS We observed RRS through in situ simulations in 2 wards and conducted the debriefings as focus group interviews. By arranging a separate focus group interview, we included the perspectives of intensive care unit personnel. RESULTS Healthcare professionals appreciated the standardized use of the National Early Warning Score, when combined with clinical knowledge and experience, structured communication, and interprofessional collaboration. However, we identified salient challenges in RRS, for example, unwanted variation in recognition competence, and inconsistent routines in education and documentation. Furthermore, we found that a lack of interprofessional trust, different understandings of RRS protocol, and signs of low psychological safety in the wards disrupted collaboration. To help remedy identified challenges, healthcare professionals requested shared arenas for learning, such as in situ simulation training. CONCLUSIONS Through system probing, we described the inner workings of RRS and revealed the challenges that require more attention. Healthcare professionals depend on structured RRS education, training, and resources to operate such a system. In this study, they request interventions like in situ simulation training as an interprofessional educational arena to improve patient care. This is a relevant field for further research. The Consolidated Criteria for Reporting Qualitative Studies Checklist was followed to ensure rigor in the study.
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Affiliation(s)
- Siri Lerstøl Olsen
- From the Department of Quality and Health Technology, The Faculty of Health Sciences, SHARE—Centre for Resilience in Healthcare, University of Stavanger
- Stavanger University Hospital, Stavanger, Norway
| | | | - Britt Sætre Hansen
- From the Department of Quality and Health Technology, The Faculty of Health Sciences, SHARE—Centre for Resilience in Healthcare, University of Stavanger
- Stavanger University Hospital, Stavanger, Norway
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Liu SI, Shikar M, Gante E, Prufeta P, Ho K, Barie PS, Winchell RJ, Lee JI. Improving Communication and Response to Clinical Deterioration to Increase Patient Safety in the Intensive Care Unit. Crit Care Nurse 2022; 42:33-43. [PMID: 36180058 DOI: 10.4037/ccn2022295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND In the critical care setting, early recognition of clinical decompensation is imperative to trigger prompt intervention and optimize patient outcomes. LOCAL PROBLEM In a 20-bed surgical intensive care unit of an urban academic medical center, cases of clinical deterioration that highlighted opportunities to improve the communication process prompted a reassessment of health care provider roles and responsibilities. METHODS A quality improvement initiative was implemented to enhance communication among intensive care unit clinical staff members, improve the timeliness of reporting clinical deterioration, and ensure implementation of timely, appropriate interventions to eliminate adverse outcomes. INTERVENTIONS Nurses were surveyed to determine their perceptions of communication and collaboration among providers. Education was provided that focused on familiarizing nurses with clinical conditions necessitating direct notification of the attending surgical intensivist and included review of a case in which escalation of care did not occur. Multidisciplinary rounds were expanded to engage night-shift nurses in clinical discussions and decision-making. A template was created to document episodes of escalation in the electronic health record. RESULTS Since implementation of the quality improvement interventions, no incidents of patient harm or death related to failure to escalate have occurred to date. A total of 16 episodes of escalation for clinical deterioration were documented in the electronic health record. Most nurses reported an increased level of confidence in understanding when to escalate concerns about clinical deterioration. CONCLUSION Implementing a multimodal program to empower nurses to escalate clinical concerns directly to the attending physician eliminated adverse events related to failure to escalate.
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Affiliation(s)
- Susan I Liu
- Susan I. Liu is a nurse clinician, Division of Critical Care Nursing, Department of Nursing, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Morgan Shikar
- Morgan Shikar is a patient care director, Division of Critical Care Nursing, Department of Nursing, NewYork-Presbyterian Hospital/ Weill Cornell Medical Center
| | - Emily Gante
- Emily Gante is a patient care director, Division of Critical Care Nursing, Department of Nursing, NewYork-Presbyterian Hospital/ Weill Cornell Medical Center
| | - Patricia Prufeta
- Patricia Prufeta is the Director of Nursing, Division of Critical Care Nursing, Department of Nursing, NewYork-Presbyterian Hospital/Weill Cornell Medical Center
| | - Kaylee Ho
- Kaylee Ho is a biostatistician, Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Philip S Barie
- Philip S. Barie is a professor emeritus of surgery, Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine
| | - Robert J Winchell
- Robert J. Winchell is the Chief of the Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine
| | - Jennifer I Lee
- Jennifer I. Lee is the Vice Chair of Quality and Patient Safety and an associate professor of clinical medicine, Weill Department of Medicine, Weill Cornell Medicine
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Shiell A, Fry M, Elliott D, Elliott R. Exploration of a rapid response team model of care: A descriptive dual methods study. Intensive Crit Care Nurs 2022; 73:103294. [PMID: 36031517 DOI: 10.1016/j.iccn.2022.103294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/01/2022] [Accepted: 06/26/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Avoidable in-patient clinical deterioration results in serious adverse events and up to 80% are preventable. Rapid response systems allow early recognition and response to clinical deterioration. OBJECTIVE To explore the characteristics of a collaborative rapid response team model. DESIGN Dual methodology was used for this descriptive study. SETTING The study was conducted in a 500-bed tertiary referral hospital (Sydney, Australia). PARTICIPANTS Inpatients (>17 years) who received a rapid response team activation were included in an electronic medical audit. Participants were rapid response team members and nurses and medical doctors in two in-patient wards. METHODS A 12-month (January-December 2018) retrospective electronic health record audit and semi-structured interviews with nurses and medical doctors (July-August 2019) were conducted. Descriptive statistics summarised audit data. Interviews were transcribed and analysed thematically. RESULTS The rapid response team consulted for 2195 patients. Mean patient age was 67.9 years, and 46% of the sample was female. Activations (n = 4092) occurred most often in general medicine (n = 1124, 70.8%) units. Overall, 117 patients had >5 activations. The themes synthesised from interviews were i) managing patient deterioration before arrival of the rapid response team; ii) collaboratively managing patient deterioration at the bedside; iii) rapid response team guidance at the bedside; and iv) 'staff concern' rapid response activation. CONCLUSIONS Some patients received many activations, however few required treatment in critical care. The rapid response model was collaborative and supportive. The themes revealed a focus on patient safety, optimising early detection, and management of patient deterioration.
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Affiliation(s)
- Alexandra Shiell
- School of Nursing and Midwifery, University of Technology Sydney, Ultimo, NSW 2001, Australia; Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia.
| | - Margaret Fry
- School of Nursing and Midwifery, University of Technology Sydney, Ultimo, NSW 2001, Australia; Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia.
| | - Doug Elliott
- School of Nursing and Midwifery, University of Technology Sydney, Ultimo, NSW 2001, Australia; Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia.
| | - Rosalind Elliott
- School of Nursing and Midwifery, University of Technology Sydney, Ultimo, NSW 2001, Australia; Nursing and Midwifery Directorate, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia.
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Namen AM, Forest D, Saha AK, Xiang KR, Younger K, Maurer S, Ahmad Z, Chatterjee AB, O’Donovan C, Sy A, Peters SP, Haponik EF. DOISNORE50: a perioperative sleep questionnaire predictive of obstructive sleep apnea and postoperative medical emergency team activation. A learning health system approach to sleep questionnaire development and screening. J Clin Sleep Med 2022; 18:1909-1919. [PMID: 35499151 PMCID: PMC9340585 DOI: 10.5664/jcsm.10006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Patients with obstructive sleep apnea (OSA) have a disproportionate increase in postoperative complications and medical emergency team activation (META). We previously introduced DOISNORE50 (Diseases, Observed apnea, Insomnia, Snoring, Neck circumference > 18 inches, Obesity with BMI > 32, R = are you male, Excessive daytime sleepiness, 50 = age ≥ 50) from sleep questionnaire ISNORED using features associated with increased odds of META in perioperative patients. Performance of DOISNORE50 (DOISNORE) had yet to be tested. METHODS The performance of DOISNORE was tested along with questionnaire ISNORED and STOP-BANG questionnaires among 300 out of 392 participants without known OSA referred to the sleep lab. In study 2, the performance of DOISNORE was tested among 64,949 lives screened in perioperative assessment clinic from 2016 to 2020. RESULTS Receiver operating characteristic curve demonstrated that best performance was achieved with responses, with area under curve of 0.801. DOISNORE's predictability of OSA risk remained stable from 2018 to 2020 with area under curve of 0.78 and a Cronbach alpha of 0.65. Patients at high risk for OSA (DOISNORE ≥ 6) were associated with an increase of META (odds ratio 1.30, 95% confidence interval 1.12-1.45). Higher relative risk was noted among patients with congestive heart failure and hypercapnia. CONCLUSIONS DOISNORE is predictive of OSA and postoperative META. Perioperative strategies against META should consider DOISNORE questionnaire and focused screening among patients with heart failure and hypercapnia. CITATION Namen AM, Forest D, Saha AK, et al. DOISNORE50: a perioperative sleep questionnaire predictive of obstructive sleep apnea and postoperative medical emergency team activation. A learning health system approach to sleep questionnaire development and screening. J Clin Sleep Med. 2022;18(8):1909-1919.
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Affiliation(s)
- Andrew M. Namen
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina,Address correspondence to: Andrew M. Namen, MD, Atrium Health Wake Forest Baptist Medical Center Blvd., Winston–Salem, NC 27006; Tel: (336) 716-4649;
| | | | - Amit K. Saha
- Department of Anesthesiology and Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Kang Rui Xiang
- Section on Pulmonary Critical Care and Allergy and Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Sheila Maurer
- Section on Pulmonary Critical Care and Allergy and Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Zeeshan Ahmad
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Arjun B. Chatterjee
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Cormac O’Donovan
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Alexander Sy
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Stephen P. Peters
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Edward F. Haponik
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Kirby L, Chagan J, Adams C, Duns N, Haddad M, Pearson S, Tegg O, Goh CT. A Decade of Pediatric Intensive Care Outreach and the Deteriorating Child—The Relationship between Dose and Outcomes in a Tertiary Children's Hospital. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1750298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
AbstractThe aim of this study is to evaluate the amalgamation and maturation of a Pediatric Intensive Care Outreach Service (PICOS) with a rapid response system (RRS) and associated outcomes over a 10-year period. It is a single-center retrospective study analyzing patient outcomes within the context of significant organizational changes introducing a track and trigger RRS called Between the Flags (BTF) and evolution of this system to electronic observation charting and alerts (eBTF) in a tertiary metropolitan children's hospital. Children on inpatient wards who required urgent activation of the RRS and admission to the pediatric intensive care unit (PICU) between 2009 and 2018 were included. Three cohorts were identified according to the system changes—pre-BTF (2009–2011), BTF (2012–2017), and eBTF (2017–2018). The PICOS dose (number of activations per 1000 hospital admissions) increased with the introduction of BTF and the RRS and this trend continued following eBTF. The number of PICU admissions via the PICOS did not vary across the decade. When comparing the pre-BTF to the BTF group, PICU mortality decreased (p < 0.05), Pediatric Index of Mortality 2 Risk of Death scores improved, and hospital length of stay decreased (p < 0.05) in the BTF group. Introduction of a track and trigger RRS and electronic charting augmenting an existing PICOS is associated with increasing dose and workload, with no significant impact on PICU admission rates or length of stay. PICOS patient mortality has notably decreased with the introduction of an RRS; however, this impact was not sustained with the addition of electronic charting and alerts in the patient medical record.
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Affiliation(s)
- Lynette Kirby
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Jayshan Chagan
- School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - Catherine Adams
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Natalie Duns
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Michael Haddad
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Sarah Pearson
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Oliver Tegg
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Chong Tien Goh
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Rihari-Thomas J, Whittam S, Goncharov L, Slade D, McElduff B, Pritchard T, McMahon J, Coventry A, Coughlan K, Steadward Y, Taylor J, Thornton A, Riddell K, Tuqiri K, Olesen K, Dahm MR, Chien L, Kelly P, McInnes E, Middleton S. Assessment and communication excellence for safe patient outcomes (ACCELERATE): A stepped-wedge cluster randomised trial protocol. Collegian 2022. [DOI: 10.1016/j.colegn.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Smith D, Cartwright M, Dyson J, Hartin J, Aitken LM. Selecting intervention content to target barriers and enablers of recognition and response to deteriorating patients: an online nominal group study. BMC Health Serv Res 2022; 22:766. [PMID: 35689227 PMCID: PMC9186287 DOI: 10.1186/s12913-022-08128-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/23/2022] [Indexed: 12/02/2022] Open
Abstract
Background Patients who deteriorate in hospital wards without appropriate recognition and/or response are at risk of increased morbidity and mortality. Track-and-trigger tools have been implemented internationally prompting healthcare practitioners (typically nursing staff) to recognise physiological changes (e.g. changes in blood pressure, heart rate) consistent with patient deterioration, and then to contact a practitioner with expertise in management of acute/critical illness. Despite some evidence these tools improve patient outcomes, their translation into clinical practice is inconsistent internationally. To drive greater guideline adherence in the use of the National Early Warning Score tool (a track-and-trigger tool used widely in the United Kingdom and parts of Europe), a theoretically informed implementation intervention was developed (targeting nursing staff) using the Theoretical Domains Framework (TDF) version 2 and a taxonomy of Behaviour Change Techniques (BCTs). Methods A three-stage process was followed: 1. TDF domains representing important barriers and enablers to target behaviours derived from earlier published empirical work were mapped to appropriate BCTs; 2. BCTs were shortlisted using consensus approaches within the research team; 3. shortlisted BCTs were presented to relevant stakeholders in two online group discussions where nominal group techniques were applied. Nominal group participants were healthcare leaders, senior clinicians, and ward-based nursing staff. Stakeholders individually generated concrete strategies for operationalising shortlisted BCTs (‘applications’) and privately ranked them according to acceptability and feasibility. Ranking data were used to drive decision-making about intervention content. Results Fifty BCTs (mapped in stage 1) were shortlisted to 14 (stage 2) and presented to stakeholders in nominal groups (stage 3) alongside example applications. Informed by ranking data from nominal groups, the intervention was populated with 12 BCTs that will be delivered face-to-face, to individuals and groups of nursing staff, through 18 applications. Conclusions A description of a theory-based behaviour change intervention is reported, populated with BCTs and applications generated and/or prioritised by stakeholders using replicable consensus methods. The feasibility of the proposed intervention should be tested in a clinical setting and the content of the intervention elaborated further to permit replication and evaluation. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08128-6.
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Affiliation(s)
- Duncan Smith
- School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK. .,Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, Euston Road, London, NW1 2BU, UK.
| | - Martin Cartwright
- School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK
| | - Judith Dyson
- Reader in Implementation Science, Birmingham City University, Westbourne Road, Edgbaston, Birmingham, B15 3TN, UK
| | - Jillian Hartin
- Patient Emergency Response & Resuscitation Team (PERRT), University College London Hospitals NHS Foundation Trust, Euston Road, London, NW1 2BU, UK
| | - Leanne M Aitken
- School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK.,School of Nursing and Midwifery, Griffith University, Nathan, QLD, 4111, Australia
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Costs, benefits and the prevention of patient deterioration. J Clin Monit Comput 2022; 36:1245-1247. [PMID: 35616798 DOI: 10.1007/s10877-022-00874-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 10/18/2022]
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50
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Pritchard ALM, Chin KL, Story DA, Smart P, Jones DA, See E, Nazareth JM. The epidemiology of rapid response team activation amongst patients undergoing major gastrointestinal surgery. Aust Crit Care 2022:S1036-7314(22)00059-5. [DOI: 10.1016/j.aucc.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/16/2022] [Accepted: 04/19/2022] [Indexed: 10/18/2022] Open
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