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Mauz N, Bouisse M, Cahn JY, Kaphan E, Truche AS, Thiebaut-Bertrand A, Carré M, Bulabois CE, Hamidfar-Roy R, Schwebel C, Park S, Labarere J, Terzi N. Rapid response system for critically ill patients with haematological malignancies: A pre- and post-intervention study. Eur J Haematol 2024. [PMID: 38780264 DOI: 10.1111/ejh.14228] [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: 01/24/2024] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND This study aimed to determine whether implementing a rapid response system (RRS) is associated with improved short-term outcomes in critically ill patients with haematological malignancies. METHODS Our monocentric pre- versus post-intervention study was conducted between January 2012 and April 2020. RRS was activated at early signs of haemodynamic or respiratory failure. The primary outcome was the reduction in Sequential Organ Failure Assessment (SOFA) score on Day 3 after intensive care unit (ICU) admission. Secondary outcomes included time to ICU admission and mortality. RESULTS A total of 209 patients with a median age of 59 years were enrolled (108 in the pre-intervention period and 101 in the post-intervention period). 22% of them had received an allogeneic transplant. The post-intervention period was associated with a shorter time to ICU admission (195 vs. 390 min, p < .001), a more frequent favourable trend in SOFA score (57% vs. 42%, adjusted odds ratio, 2.02, 95% confidence interval, 1.09 to 3.76), no significant changes in ICU (22% vs. 26%, p = .48) and 1-year (62% vs. 58%, p = .62) mortality rates. CONCLUSION Detection of early organ failure and activation of an RRS was associated with faster ICU admission and lower SOFA scores on Day 3 of admission in critically ill patients with haematological malignancies.
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Affiliation(s)
- N Mauz
- Haematology Department, Annecy Hospital, Epagny-Metz-Tessy, France
- Intensive Care Unit, Annecy Hospital, Epagny-Metz-Tessy, France
| | - M Bouisse
- Clinical Epidemiology Unit, Grenoble Alpes Hospital, University Grenoble Alpes, TIMC-UMR 5525 CNRS, Grenoble, France
| | - J Y Cahn
- Haematology Department, Grenoble Alpes Hospital, University Grenoble Alpes, Grenoble, France
| | - E Kaphan
- Haematology Department, Saint Louis Hospital, Paris, France
| | - A-S Truche
- Medical Intensive Care Unit, Grenoble Alpes Hospital, Grenoble, France
| | - A Thiebaut-Bertrand
- Haematology Department, Grenoble Alpes Hospital, University Grenoble Alpes, Grenoble, France
| | - M Carré
- Haematology Department, Grenoble Alpes Hospital, University Grenoble Alpes, Grenoble, France
| | - C-E Bulabois
- Haematology Department, Grenoble Alpes Hospital, University Grenoble Alpes, Grenoble, France
| | - R Hamidfar-Roy
- Pneumology Department, Grenoble Alpes Hospital, Grenoble, France
| | - C Schwebel
- Medical Intensive Care Unit, Grenoble Alpes Hospital, Grenoble, France
| | - S Park
- Haematology Department, Grenoble Alpes Hospital, University Grenoble Alpes, Grenoble, France
- Inserm U 1209, CNRS UMR 5309, Team Epigenetics Regulation, Institute for Advanced Biosciences, University Grenoble Alpes, Grenoble, France
| | - J Labarere
- Clinical Epidemiology Unit, Grenoble Alpes Hospital, University Grenoble Alpes, TIMC-UMR 5525 CNRS, Grenoble, France
| | - N Terzi
- Medical Intensive Care Unit, Rennes University Hospital, Rennes, France
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Honarmand K, Wax RS, Penoyer D, Lighthall G, Danesh V, Rochwerg B, Cheatham ML, Davis DP, DeVita M, Downar J, Edelson D, Fox-Robichaud A, Fujitani S, Fuller RM, Haskell H, Inada-Kim M, Jones D, Kumar A, Olsen KM, Rowley DD, Welch J, Baldisseri MR, Kellett J, Knowles H, Shipley JK, Kolb P, Wax SP, Hecht JD, Sebat F. Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023. Crit Care Med 2024; 52:314-330. [PMID: 38240510 DOI: 10.1097/ccm.0000000000006072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
RATIONALE Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Randy S Wax
- Department of Critical Care Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
- Department of Critical Care, Lakeridge Health, Oshawa, ON, Canada
| | - Daleen Penoyer
- Center for Nursing Research and Advanced Nursing Practice, Orlando Health, Orlando, FL
| | - Geoffery Lighthall
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University School of Medicine, Palo Alto, CA
- Veterans Affairs Medical Center, Palo Alto, CA
| | - Valerie Danesh
- Center for Applied Health Research, Baylor Scott and White Health, Dallas, TX
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michael L Cheatham
- Division of Surgical Education, Orlando Regional Medical Center, Orlando, FL
| | | | - Michael DeVita
- Columbia Vagelos College of Physicians and Surgeons, Department of Medicine Harlem Hospital Medical Center, New York City, NY
| | - James Downar
- Division of Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Dana Edelson
- Division of Internal Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL
| | - Alison Fox-Robichaud
- Division of Critical Care, Department of Internal Medicine, Thrombosis and Atherosclerosis Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Shigeki Fujitani
- Division of Critical Care, Department of Emergency Medicine, Saint Marianna University, Kawasaki, Japan
| | - Raeann M Fuller
- Division of Trauma and Critical Care, Department of Emergency Medicine, Advocate Condell Medical Center, Libertyville, IL
| | | | - Matthew Inada-Kim
- Department of Acute Medicine, Hampshire Hospitals NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Daryl Jones
- Division of Surgery, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Anand Kumar
- Division of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Keith M Olsen
- University of Nebraska Medical Center, Nebraska Medical Center, Omaha, NE
| | - Daniel D Rowley
- Respiratory Therapy Services, University of Virginia Medical Center, Charlottesville, VA
| | - John Welch
- Critical Care Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Marie R Baldisseri
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John Kellett
- Department of Emergency Medicine, University of Southern Denmark, Odense, Denmark
| | - Heidi Knowles
- Department of Emergency Medicine, John Peter Smith Health Network, Fort Worth, TX
| | - Jonathan K Shipley
- Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN
| | - Philipp Kolb
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Family Medicine, Dalhousie University, Halifax, ON, Canada
| | - Sophie P Wax
- Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Jonathan D Hecht
- School of Nursing, The University of Texas at Austin, Austin, TX
| | - Frank Sebat
- Division of Internal Medicine, Mercy Medical Center, Redding, CA
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Prower E, Hadfield S, Saha R, Woo T, Ang KM, Metaxa V. A critical care outreach team under strain - Evaluation of the service provided to patients with haematological malignancy during the Covid-19 pandemic. J Crit Care 2022; 71:154109. [PMID: 35843047 PMCID: PMC9282870 DOI: 10.1016/j.jcrc.2022.154109] [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: 04/03/2022] [Revised: 06/18/2022] [Accepted: 06/28/2022] [Indexed: 11/25/2022]
Abstract
Purpose Critical Care Outreach Teams (CCOTs) have been associated with improved outcomes in patients with haematological malignancy (HM). This study aims to describe CCOT activation by patients with HM before and during the Covid-19 pandemic, assess amny association with worse outcomes, and examine the psychological impact on the CCOT. Materials and methods A retrospective, mixed-methods analysis was performed in HM patients reviewed by the CCOT over a two-year period, 01 July 2019 to 31 May 2021. Results The CCOT increased in size during the surge period and reviewed 238 HM patients, less than in the pre- and post-surge periods. ICU admission in the baseline, surge and the non-surge periods were 41.7%, 10.4% and 47.9% respectively. ICU mortality was 22.5%, 0% and 21.7% for the same times. Time to review was significantly decreased (p = 0.012). Semi-structured interviews revealed four themes of psychological distress: 1) time-critical work; 2) non-evidence based therapies; 3) feelings of guilt; 4) increased decision-making responsibility. Conclusions Despite the increase in total hospital referrals, the number of patients with HM that were reviewed during the surge periods decreased, as did their ICU admission rate and mortality. The quality of care provided was not impaired, as reflected by the number of patients receiving bedside reviews and the shorter-than-pre-pandemic response time.
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Affiliation(s)
- Emma Prower
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Sophie Hadfield
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Rohit Saha
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Timothy Woo
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Kar Mun Ang
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK.
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Tetlow S, Anandanadesan R, Taheri L, Pagkalidou E, De Lavallade H, Metaxa V. High-flow nasal cannula oxygen in patients with haematological malignancy: a retrospective observational study. Ann Hematol 2022; 101:1191-1199. [PMID: 35394147 DOI: 10.1007/s00277-022-04824-9] [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: 11/06/2021] [Accepted: 03/21/2022] [Indexed: 01/05/2023]
Abstract
Patients with haematological malignancies (HM) face high rates of intensive care unit (ICU) admission and mortality. High-flow nasal cannula oxygen (HFNCO) is increasingly used to support HM patients in ward settings, but there is limited evidence on the safety and efficacy of HFNCO in this group. We retrospectively reviewed all HM patients receiving ward-based HFNCO, supervised by a critical care outreach service (CCOS), from January 2014 to January 2019. We included 130 consecutive patients. Forty-three (33.1%) were weaned off HFNCO without ICU admission. Eighty-seven (66.9%) were admitted to ICU, 20 (23.3%) required non-invasive and 34 (39.5%) invasive mechanical ventilation. ICU and hospital mortality were 42% and 55% respectively. Initial FiO2 < 0.4 (OR 0.27, 95% CI 0.09-0.81, p = 0.019) and HFNCO use on the ward > 1 day (OR 0.16, 95% CI 0.04, 0.59, p = 0.006) were associated with reduced likelihood for ICU admission. Invasive ventilation was associated with reduced survival (OR 0.27, 95%CI 0.1-0.7, p = 0.007). No significant adverse events were reported. HM patients receiving ward-based HFNCO have higher rates of ICU admission, but comparable hospital mortality to those requiring CCOS review without respiratory support. Results should be interpreted cautiously, as the model proposed depends on the existence of CCOS.
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Affiliation(s)
- Simon Tetlow
- University College Hospital NHS Foundation Trust, 235 Euston Rd, Bloomsbury, London, NW1 2BU, UK.
| | | | - Leila Taheri
- Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Eirini Pagkalidou
- School of Medicine, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloniki, Greece
| | - Hugues De Lavallade
- Department of Haematological Medicine, King's College Hospital, Denmark Hill, Brixton, London, SE5 9RS, UK
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital, Denmark Hill, Brixton, London, SE5 9RS, UK
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Abstract
The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.
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Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma MHM, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn JC. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S222-S283. [PMID: 33084395 DOI: 10.1161/cir.0000000000000896] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.
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8
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Greif R, Bhanji F, Bigham BL, Bray J, Breckwoldt J, Cheng A, Duff JP, Gilfoyle E, Hsieh MJ, Iwami T, Lauridsen KG, Lockey AS, Ma MHM, Monsieurs KG, Okamoto D, Pellegrino JL, Yeung J, Finn JC, Baldi E, Beck S, Beckers SK, Blewer AL, Boulton A, Cheng-Heng L, Yang CW, Coppola A, Dainty KN, Damjanovic D, Djärv T, Donoghue A, Georgiou M, Gunson I, Krob JL, Kuzovlev A, Ko YC, Leary M, Lin Y, Mancini ME, Matsuyama T, Navarro K, Nehme Z, Orkin AM, Pellis T, Pflanzl-Knizacek L, Pisapia L, Saviani M, Sawyer T, Scapigliati A, Schnaubelt S, Scholefield B, Semeraro F, Shammet S, Smyth MA, Ward A, Zace D. Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A188-A239. [PMID: 33098918 DOI: 10.1016/j.resuscitation.2020.09.014] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.
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9
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Gershkovich B, Fernando SM, Herritt B, Castellucci LA, Rochwerg B, Munshi L, Mehta S, Seely AJE, McIsaac DI, Tran A, Reardon PM, Tanuseputro P, Kyeremanteng K. Outcomes of hospitalized hematologic oncology patients receiving rapid response system activation for acute deterioration. Crit Care 2019; 23:286. [PMID: 31455376 PMCID: PMC6712869 DOI: 10.1186/s13054-019-2568-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/13/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with hematologic malignancies who are admitted to hospital are at increased risk of deterioration and death. Rapid response systems (RRSs) respond to hospitalized patients who clinically deteriorate. We sought to describe the characteristics and outcomes of hematologic oncology inpatients requiring rapid response system (RRS) activation, and to determine the prognostic accuracy of the SIRS and qSOFA criteria for in-hospital mortality of hematologic oncology patients with suspected infection. METHODS We used registry data from two hospitals within The Ottawa Hospital network, between 2012 and 2016. Consecutive hematologic oncology inpatients who experienced activation of the RRS were included in the study. Data was gathered at the time of RRS activation and assessment. The primary outcome was in-hospital mortality. Logistical regression was used to evaluate for predictors of in-hospital mortality. RESULTS We included 401 patients during the study period. In-hospital mortality for all included patients was 41.9% (168 patients), and 145 patients (45%) were admitted to ICU following RRS activation. Among patients with suspected infection at the time of RRS activation, Systemic Inflammatory Response Syndrome (SIRS) criteria had a sensitivity of 86.9% (95% CI 80.9-91.6) and a specificity of 38.2% (95% CI 31.9-44.8) for predicting in-hospital mortality, while Quick Sequential Organ Failure Assessment (qSOFA) criteria had a sensitivity of 61.9% (95% CI 54.1-69.3) and a specificity of 91.4% (95% CI 87.1-94.7). Factors associated with increased in-hospital mortality included transfer to ICU after RRS activation (adjusted odds ratio [OR] 3.56, 95% CI 2.12-5.97) and a higher number of RRS activations (OR 2.45, 95% CI 1.63-3.69). Factors associated with improved survival included active malignancy treatment at the time of RRS activation (OR 0.54, 95% CI 0.34-0.86) and longer hospital length of stay (OR 0.78, 95% CI 0.70-0.87). CONCLUSIONS Hematologic oncology inpatients requiring RRS activation have high rates of subsequent ICU admission and mortality. ICU admission and higher number of RRS activations are associated with increased risk of death, while active cancer treatment and longer hospital stay are associated with lower risk of mortality. Clinicians should consider these factors in risk-stratifying these patients during RRS assessment.
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Affiliation(s)
- Benjamin Gershkovich
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON K1H 8L6 Canada
| | - Shannon M. Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON Canada
| | - Brent Herritt
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Lana A. Castellucci
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
| | - Laveena Munshi
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
| | - Andrew J. E. Seely
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Department of Surgery, University of Ottawa, Ottawa, ON Canada
| | - Daniel I. McIsaac
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON Canada
| | - Alexandre Tran
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Department of Surgery, University of Ottawa, Ottawa, ON Canada
| | - Peter M. Reardon
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON Canada
| | - Peter Tanuseputro
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON Canada
- Institut du Savoir Montfort, Ottawa, ON Canada
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10
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Taheri L, Anandanadesan R, de Lavallade H, Pagkalidou E, Pagliuca A, Mufti G, Auzinger G, Metaxa V. The role of a critical care outreach service in the management of patients with haematological malignancy. J Intensive Care Soc 2019; 20:327-334. [PMID: 31695737 DOI: 10.1177/1751143719855201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Although improvement in survival from haematological malignancies has been reported, a substantial number of these patients develop life threatening complications. Critical care outreach services (CCOS) aim to avert inappropriate ICU admissions, while ensuring timely patient review. Methods We retrospectively analysed patients with haematological malignancy reviewed by an outreach service between January 2014 and December 2015 at a single institution. The aim of our study was to describe the patient population assessed by a well-established outreach team, identify predictors of ICU admission, as well as ICU and hospital mortality. Results Sixty of 126 patients reviewed (47.6%) were admitted to ICU. ICU and hospital mortality were 25.3% and 45.2%, respectively. The odds of being admitted to ICU was 13 times higher (p = 0.013) if the patient was referred for hypoxia, 20 times higher (p = 0.006) if they were referred for sepsis or 14 times higher (p = 0.027) if they were referred to CCOS for hypotension, compared to when the team was automatically alerted. The odds of not surviving hospital admission increased 1.27 times for every extra day of CCOS review (p = 0.02). When a patient was referred having a refractory or progressive haematological condition, the odds of not surviving to hospital discharge increased by four or 12 times, respectively, compared to when the referred patient was in remission. Receiving high flow nasal cannula oxygen (HFNCO) was associated with a reduction in ICU admission (p = 0.03), irrespective of the underlying diagnosis, performance status or location of delivery. The CCOS participated in end-of-life discussions in 29% patients. Conclusions ICU and hospital mortality of patients with haemato-oncological malignancy continue to improve. CCOS are heavily involved in the recognition and management of these patients, as well as in the facilitation of end-of-life discussions. Sepsis was associated with increased risk of ICU admission and mortality. Initiation of HFNCO outside ICU appears to be feasible and safe and was not associated with increasing risk in this single centre study.
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Affiliation(s)
- Leila Taheri
- South Thames Training Scheme, London Deanery, London, UK
| | - Rathai Anandanadesan
- South Thames/South East School of Anaesthesia (SESA), London LETB, London Deanery, London, UK
| | - Hugues de Lavallade
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Eirini Pagkalidou
- School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonio Pagliuca
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Ghulam Mufti
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Georg Auzinger
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
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11
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Kondakci M, Reinbach MC, Germing U, Kobbe G, Fenk R, Schroeder T, Quader J, Zeus T, Rassaf T, Haas R. Interaction of increasing ICU survival and admittance policies in patients with hematologic neoplasms: A single center experience with 304 patients. Eur J Haematol 2019; 102:265-274. [DOI: 10.1111/ejh.13206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 12/02/2018] [Accepted: 12/06/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Mustafa Kondakci
- Department of Haematology, Oncology and Clinical Immunology, Medical Faculty University Hospital Duesseldorf Duesseldorf Germany
| | - Marc C. Reinbach
- Department of Haematology, Oncology and Clinical Immunology, Medical Faculty University Hospital Duesseldorf Duesseldorf Germany
| | - Ulrich Germing
- Department of Haematology, Oncology and Clinical Immunology, Medical Faculty University Hospital Duesseldorf Duesseldorf Germany
| | - Guido Kobbe
- Department of Haematology, Oncology and Clinical Immunology, Medical Faculty University Hospital Duesseldorf Duesseldorf Germany
| | - Roland Fenk
- Department of Haematology, Oncology and Clinical Immunology, Medical Faculty University Hospital Duesseldorf Duesseldorf Germany
| | - Thomas Schroeder
- Department of Haematology, Oncology and Clinical Immunology, Medical Faculty University Hospital Duesseldorf Duesseldorf Germany
| | - Jasmin Quader
- Department of Haematology, Oncology and Clinical Immunology, Medical Faculty University Hospital Duesseldorf Duesseldorf Germany
| | - Tobias Zeus
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty University Hospital Duesseldorf Duesseldorf Germany
| | - Tienush Rassaf
- Department of Cardiology, Medical Faculty University Hospital Essen Essen Germany
| | - Rainer Haas
- Department of Haematology, Oncology and Clinical Immunology, Medical Faculty University Hospital Duesseldorf Duesseldorf Germany
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Nakamura M, Fujii N, Shimizu K, Ikegawa S, Seike K, Inomata T, Sando Y, Fujii K, Nishimori H, Matsuoka KI, Morimatsu H, Maeda Y. Long-term outcomes in patients treated in the intensive care unit after hematopoietic stem cell transplantation. Int J Hematol 2018; 108:622-629. [PMID: 30238198 DOI: 10.1007/s12185-018-2536-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 01/27/2023]
Abstract
The number of patients who are successfully discharged from the intensive care unit (ICU) after hematopoietic stem cell transplantation (HSCT) remains limited. Most previous studies have evaluated short-term outcomes using ICU mortality; there have been comparatively fewer reports of long-term outcomes. We retrospectively analyzed 39 HSCT patients admitted to the ICU for the first time between April 2008 and July 2014. Performance status was evaluated in four long-term survivors in July 2016. Median age at ICU admission was 54 years (range 30-68). In total, 33 patients (70.2%) required mechanical ventilation and 31 patients (66%) required dialysis. The median OS from first ICU admission was 41 days (95% confidence interval [CI]: 22-64) and the 1-year survival rate was 12.8% (95% CI 4.7-25.2). No statistically significant factors were associated with short-term outcomes. Among long-term outcomes, a second or subsequent HSCT and neutropenia at ICU admission were significant risk factors. Four of 10 ICU survivors have survived with good performance status for a median of 1994 (1203-2633) days. Our results suggest that the number of prior transplants and neutropenia at ICU admission may influence OS.
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Affiliation(s)
- Makoto Nakamura
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
- Department of Transfusion Medicine, Okayama University Hospital, Okayama, Japan
| | - Nobuharu Fujii
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
- Department of Transfusion Medicine, Okayama University Hospital, Okayama, Japan.
| | - Kazuyoshi Shimizu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Shuntaro Ikegawa
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Keisuke Seike
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
- Department of Transfusion Medicine, Okayama University Hospital, Okayama, Japan
| | - Tomoko Inomata
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yasuhisa Sando
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
- Department of Transfusion Medicine, Okayama University Hospital, Okayama, Japan
| | - Keiko Fujii
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
- Department of Transfusion Medicine, Okayama University Hospital, Okayama, Japan
| | - Hisakazu Nishimori
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Ken-Ichi Matsuoka
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Yoshinobu Maeda
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
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Allogeneic stem cell transplantation recipients requiring intensive care: time is of the essence. Ann Hematol 2018; 97:1601-1609. [DOI: 10.1007/s00277-018-3320-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/25/2018] [Indexed: 01/13/2023]
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14
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Saillard C, Darmon M, Bisbal M, Sannini A, Chow-Chine L, Faucher M, Lengline E, Vey N, Blaise D, Azoulay E, Mokart D. Critically ill allogenic HSCT patients in the intensive care unit: a systematic review and meta-analysis of prognostic factors of mortality. Bone Marrow Transplant 2018; 53:1233-1241. [DOI: 10.1038/s41409-018-0181-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/08/2018] [Accepted: 03/25/2018] [Indexed: 12/13/2022]
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Alaa AM, Yoon J, Hu S, van der Schaar M. Personalized Risk Scoring for Critical Care Prognosis Using Mixtures of Gaussian Processes. IEEE Trans Biomed Eng 2018; 65:207-218. [PMID: 28463183 DOI: 10.1109/tbme.2017.2698602] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this paper, we develop a personalized real-time risk scoring algorithm that provides timely and granular assessments for the clinical acuity of ward patients based on their (temporal) lab tests and vital signs; the proposed risk scoring system ensures timely intensive care unit admissions for clinically deteriorating patients. METHODS The risk scoring system is based on the idea of sequential hypothesis testing under an uncertain time horizon. The system learns a set of latent patient subtypes from the offline electronic health record data, and trains a mixture of Gaussian Process experts, where each expert models the physiological data streams associated with a specific patient subtype. Transfer learning techniques are used to learn the relationship between a patient's latent subtype and her static admission information (e.g., age, gender, transfer status, ICD-9 codes, etc). RESULTS Experiments conducted on data from a heterogeneous cohort of 6321 patients admitted to Ronald Reagan UCLA medical center show that our score significantly outperforms the currently deployed risk scores, such as the Rothman index, MEWS, APACHE, and SOFA scores, in terms of timeliness, true positive rate, and positive predictive value. CONCLUSION Our results reflect the importance of adopting the concepts of personalized medicine in critical care settings; significant accuracy and timeliness gains can be achieved by accounting for the patients' heterogeneity. SIGNIFICANCE The proposed risk scoring methodology can confer huge clinical and social benefits on a massive number of critically ill inpatients who exhibit adverse outcomes including, but not limited to, cardiac arrests, respiratory arrests, and septic shocks.
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Tavares M, Lemiale V, Mokart D, Pène F, Lengliné E, Kouatchet A, Mayaux J, Vincent F, Nyunga M, Bruneel F, Rabbat A, Lebert C, Perez P, Meert AP, Benoit D, Darmon M, Azoulay E. Determinants of 1-year survival in critically ill acute leukemia patients: a GRRR-OH study. Leuk Lymphoma 2017; 59:1323-1331. [PMID: 28901791 DOI: 10.1080/10428194.2017.1375106] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Acute leukemia (AL) is the most common hematological malignancy requiring intensive care unit (ICU) management. Data on long-term survival are limited. This is a post hoc analysis of the prospective multicenter data from France and Belgium: A Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique [A Research Group on Acute Respiratory Failure in Onco-Hematological Patients (French)] Study, to identify determinants of 1-year survival in critically ill AL patients. A total of 278 patients were admitted in the 17 participating ICUs. Median age was 58 years and 70% had newly diagnosed leukemia. ICU mortality rate was 28.6 and 39.6% of the patients alive at 1 year. Admission for intensive monitoring was independently associated with better 1-year survival by multivariate analysis. Conversely, relapsed/refractory disease, secondary leukemia, mechanical ventilation and renal replacement therapy were independently associated with 1-year mortality. This study confirms the impact of organ dysfunction on long-term survival in ICU patients with AL. Follow-up studies to assess respiratory and renal recovery are warranted.
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Affiliation(s)
- Márcio Tavares
- a ICU , Saint Louis University Hospital , Paris , France
| | | | - Djamel Mokart
- b ICU , Paoli Calmettes Institut , Marseille , France
| | | | - Etienne Lengliné
- d Hematology Department , Saint Louis University Hospital , Paris , France
| | | | - Julien Mayaux
- f ICU Pitié Salpétrière University Hospital , Paris , France
| | | | | | | | - Antoine Rabbat
- j Respiratory ICU , Cochin University Hospital , Paris , France
| | - Christine Lebert
- k ICU Les Oudaries La Roche Sur Yon Hospital , Les Oudairies -La Roche-sur-Yon cedex , France
| | - Pierre Perez
- l ICU , Brabois University Hospital , Vandoeuvre-lès-Nancy , France
| | | | | | - Michael Darmon
- o ICU , Saint Etienne University Hospital , Saint-Etienne , France
| | - Elie Azoulay
- a ICU , Saint Louis University Hospital , Paris , France
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[Transfer of allogeneic stem cell transplant recipients to the intensive care unit: Guidelines from the Francophone society of marrow transplantation and cellular therapy (SFGM-TC)]. Bull Cancer 2016; 103:S220-S228. [PMID: 27816169 DOI: 10.1016/j.bulcan.2016.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 09/01/2016] [Indexed: 12/31/2022]
Abstract
Transferring a patient undergoing an allogeneic stem cell transplantation to the intensive care unit (ICU) is always a challenging situation on a medical and psychological point of view for the patient and his relatives as well as for the medical staff. Despite the progress in hematology and intensive care during the last decade, the prognosis of these patients admitted to the ICU remains poor and mortality is around 50 %. The harmonization working party of the SFGM-TC assembled hematologists and intensive care specialist in order to improve conditions and modalities of the transfer of a patient after allogeneic stem cell transplantation to the ICU. We propose a structured medical form comprising all essential information necessary for optimal medical care on ICU.
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Critically ill allogeneic hematopoietic stem cell transplantation patients in the intensive care unit: reappraisal of actual prognosis. Bone Marrow Transplant 2016; 51:1050-61. [PMID: 27042832 DOI: 10.1038/bmt.2016.72] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 12/16/2022]
Abstract
The outcome of allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients has significantly improved over the past decade. Still, a significant number of patients require intensive care unit (ICU) management because of life-threatening complications. Literature from the 1990s reported extremely poor prognosis for critically ill allo-HSCT patients requiring ICU management. Recent data justify the use of ICU resources in hematologic patients. Yet, allo-HSCT remains an independent variable associated with mortality. However, outcomes in allo-HSCT patients have improved over time and many classic determinants of mortality have become irrelevant. The main actual prognostic factors are the need for mechanical ventilation, the presence of GvHD and the number of organ failures at ICU admission. Recently, the development of reduced-intensity conditioning regimens, early ICU admission and the increased use of noninvasive ventilation, combined with time effect and general advances in hematology, in allo-HSCT procedures and in ICU management have contributed to improve general outcome. A rational policy of ICU admission triage in these patients is very hard to define, as each decision for ICU admission is a case-by-case decision at patient bedside. The collaboration between hematologists and intensivists is crucial in this context.
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Kronick SL, Kurz MC, Lin S, Edelson DP, Berg RA, Billi JE, Cabanas JG, Cone DC, Diercks DB, Foster J(J, Meeks RA, Travers AH, Welsford M. Part 4: Systems of Care and Continuous Quality Improvement. Circulation 2015; 132:S397-413. [DOI: 10.1161/cir.0000000000000258] [Citation(s) in RCA: 191] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care 2015; 19:254. [PMID: 26070457 PMCID: PMC4489005 DOI: 10.1186/s13054-015-0973-y] [Citation(s) in RCA: 339] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/04/2015] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Although rapid response system teams have been widely adopted by many health systems, their effectiveness in reducing hospital mortality is uncertain. We conducted a meta-analysis to examine the impact of rapid response teams on hospital mortality and cardiopulmonary arrest. METHOD We conducted a systematic review of studies published from January 1, 1990, through 31 December 2013, using PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library. We included studies that reported data on the primary outcomes of ICU and in-hospital mortality or cardiopulmonary arrests. RESULTS Twenty-nine eligible studies were identified. The studies were analysed in groups based on adult and paediatric trials that were further sub-grouped on methodological design. There were 5 studies that were considered either cluster randomized control trial, controlled before after or interrupted time series. The remaining studies were before and after studies without a contemporaneous control. The implementation of RRS has been associated with an overall reduction in hospital mortality in both the adult (RR 0.87, 95 % CI 0.81-0.95, p<0.001) and paediatric (RR=0.82 95 % CI 0.76-0.89) in-patient population. There was substantial heterogeneity in both populations. The rapid response system team was also associated with a reduction in cardiopulmonary arrests in adults (RR 0.65, 95 % CI 0.61-0.70, p<0.001) and paediatric (RR=0.64 95 % CI 0.55-0.74) patients. CONCLUSION Rapid response systems were associated with a reduction in hospital mortality and cardiopulmonary arrest. Meta-regression did not identify the presence of a physician in the rapid response system to be significantly associated with a mortality reduction.
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Affiliation(s)
- Ritesh Maharaj
- Kings College London, Denmark Hill, London, SE5 9RW, UK.
- Department of Critical Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RW, UK.
- Department of Critical Care Medicine, Kings College London, Ground Floor, Cheyne Wing, Denmark Hill, London, SE5 9RS, UK.
| | - Ivan Raffaele
- Department of Critical Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RW, UK.
| | - Julia Wendon
- Kings College London, Denmark Hill, London, SE5 9RW, UK.
- Department of Critical Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RW, UK.
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McNeill G, Bryden D. Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review. Resuscitation 2013; 84:1652-67. [DOI: 10.1016/j.resuscitation.2013.08.006] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 07/22/2013] [Accepted: 08/03/2013] [Indexed: 12/15/2022]
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24
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Türkog˘lu M, Erdem GU, Suyanı E, Sancar ME, Yalçın MM, Aygencel G, Akı Z, Sucak G. Acute respiratory distress syndrome in patients with hematological malignancies. Hematology 2013; 18:123-130. [DOI: 10.1179/1607845412y.0000000038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Melda Türkog˘lu
- Department of Medical Intensive Care UnitSchool of Medicine, Gazi University Besevler, Ankara, Turkey
| | - Gökmen Umut Erdem
- Department of Medical Intensive Care UnitSchool of Medicine, Gazi University Besevler, Ankara, Turkey
| | - Elif Suyanı
- Department of HematologySchool of Medicine, Gaza University Besevler, Ankara, Turkey
| | - Muhammed Erkam Sancar
- Department of Medical Intensive Care UnitSchool of Medicine, Gazi University Besevler, Ankara, Turkey
| | | | - Gülbin Aygencel
- Department of Medical Intensive Care UnitSchool of Medicine, Gazi University Besevler, Ankara, Turkey
| | - Zeynep Akı
- Department of HematologySchool of Medicine, Gaza University Besevler, Ankara, Turkey
| | - Gülsan Sucak
- Department of HematologySchool of Medicine, Gaza University Besevler, Ankara, Turkey
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