Inhospital cardiac arrest: pre-event variables and nursing response

The impact of introducing the early warning scoring system and protocol on clinical outcomes in tertiary referral university hospital

Purpose

The aim of this study was to evaluate the impact of a hospital protocol in response to patient deterioration in general wards, stratified using the national early warning score (NEWS), on primary patient outcomes of in-hospital mortality and percentage of patients transferred to the intensive care unit (ICU).

Patients and methods

We conducted a prospective observational cohort study among adult medical patients admitted to a university hospital in Bangkok. A 4-month pre-protocol period (November 2015 to February 2016) was assigned to a control group and a protocol period (March 2016 to June 2016) was allocated to a protocol group. On admission, vital signs (respiratory rate, pulse rate, systolic blood pressure, and temperature), oxygen saturation, presence of oxygen supplementation, and neurological status were used to calculate NEWS. Patients were categorized as low, moderate, or high risk based on the NEWS. During protocol period, when patients’ conditions are critical and they are at imminent risk, the NEWS detects the event and triggers a systematic response. The response enables closed monitoring and early treatment by expert physicians to rapidly stabilize and triage the patient to a location where services meet the patient’s needs. Primary outcomes were compared between the pre-protocol and protocol groups using historical controls for the intervention, which is the availability of NEWS to staff and an associated escalation pathway.

Results

A total of 1,145 patients were included in the analysis: 564 patients in the pre-protocol group and 581 in the protocol group. The mean NEWS of patients at admission was higher in the protocol group than in the pre-protocol group (2.4±2.4 vs 1.77±2.158; P<0.001). There was no significant difference for in-hospital mortality and percentage of patients transferred to ICU between the groups. Among 95 (8.3%) patients at moderate risk, in-hospital mortality and ICU transfer percentage were lower in the protocol group than in the pre-protocol group (2.9 vs 15.4%; P=0.026; RR 0.188, 95% CI 0.037%–0.968% and 8.7 vs 26.9%; P=0.021; RR 0.322, 95% CI 0.12–0.87, respectively).

Conclusion

Implementing the NEWS with the hospital protocol did not change the overall patient’s outcomes.

Surveillance nursing diagnoses, ongoing assessment and outcomes on in-patients who suffered a cardiorespiratory arrest

Objective The purposes of this study were to examine the frequency of surveillance-oriented nursing diagnoses and interventions documented in the electronic care plans of patients who experienced a cardiac arrest during hospitalization, and to observe whether differences exist in terms of patients' profiles, surveillance measurements and outcomes. Method A descriptive, observational, retrospective, cross-sectional design, randomly including data from electronic documentation of patients who experienced a cardiac arrest during hospitalization in any of the 107 adult wards of eight acute care facilities. Descriptive statistics were used for data analysis. Two-tailed p-values are reported. Results Almost 60% of the analyzed patients' e-charts had surveillance nursing diagnoses charted in the electronic care plans. Significant differences were found for patients who had these diagnoses documented and those who had not in terms of frequency of vital signs measurements and final outcomes. Conclusion Surveillance nursing diagnoses may play a significant role in preventing acute deterioration of adult in-patients in the acute care setting.

Make vital signs great again - A call for action

Vital signs are the simplest, cheapest and probably the most important information gathered on patients in hospital. In this narrative review we present a large amount of evidence that vital signs are currently little valued, not regularly or accurately recorded, and frequently not acted on appropriately. It is probable that few hospitals would keep their accreditation with regulatory bodies if they collected and acted on their laboratory results in the same way that they collect and act on vital signs. Professional societies and regulatory bodies need to address this issue: if vital signs were more accurately and frequently measured, and acted on promptly and appropriately hospital care would be safer, better and cheaper.

Use of a modified early warning score system to reduce the rate of in-hospital cardiac arrest

Background

Physiological abnormalities are often observed in patients prior to cardiac arrest. A modified early warning score (MEWS) system was introduced, which aims to detect early abnormalities by grading vital signs, and the present study investigated its usefulness.

Methods

Based on previous reports, the Chubu Tokushukai Hospital-customized MEWS was developed in Okinawa, Japan. The MEWS was calculated among all inpatients, and the rates of in-hospital cardiac arrests (IHCAs) were compared according to the score. The warning zone (WZ) was set as 7 or more because of the high possibility of acute deterioration. The MEWS system was introduced to provide immediate interventions for patients who reached the WZ in accordance with the callout algorithm. The numbers of IHCAs were compared between the 18 months before and after introduction of the MEWS system.

Results

The numbers of patients who experienced IHCA with each score were as follows: score of 6, 1 of 556 patients (0.18 %); score of 7, 4 of 289 (1.40 %); score of 8, 2 of 114 (1.75 %); and score of 9 or more, 2 of 56 (3.57 %). There was no significant difference in the mean age or sex between before and after the introduction of the MEWS system. The rate of IHCAs per 1000 admissions decreased significantly from 5.21 (79/15,170) to 2.05 (43/17,961) (p < 0.01).

Conclusions

The Chubu Tokushukai Hospital-customized MEWS was applied to all inpatients, and the rate of IHCA decreased owing to the introduction of the system, as the system enables early interventions for patients who have the possibility of acute deterioration.

Capturing judgement strategies in risk assessments with improved quality of clinical information: How nurses' strategies differ from the ecological model

Background

Nurses’ risk assessments of patients at risk of deterioration are sometimes suboptimal. Advances in clinical simulation mean higher quality information can be used as an alternative to traditional paper-based approaches as a means of improving judgement. This paper tests the hypothesis that nurses’ judgement strategies and policies change as the quality of information used by nurses in simulation changes.

Methods

Sixty-three student nurses and 34 experienced viewed 25 paper-case based and 25 clinically simulated scenarios, derived from real cases, and judged whether the (simulated) patient was at ‘risk’ of acute deterioration. Criteria of judgement “correctness” came from the same real cases. Information relative weights were calculated to examine judgement policies of individual nurses. Group comparisons of nurses and students under both paper and clinical simulation conditions were undertaken using non parametric statistical tests. Judgment policies were also compared to the ecological statistical model. Cumulative relative weights were calculated to assess how much information nurses used when making judgements. Receiver operating characteristic (ROC) curves were generated to examine predictive accuracy amongst the nurses.

Results

There were significant variations between nurses’ judgement policies and those optimal policies determined by the ecological model. Nurses significantly underused the cues of consciousness level, respiration rate, and systolic blood pressure than the ecological model requires. However, in clinical simulations, they tended to make appropriate use of heart rate, with non-significant difference in the relative weights of heart rate between clinical simulations and the ecological model. Experienced nurses paid substantially more attention to respiration rate in the simulated setting compared to paper cases, while students maintained a similar attentive level to this cue. This led to a non-significant difference in relative weights of respiration rate between experienced nurses and students.

Conclusions

Improving the quality of information by clinical simulations significantly impacted on nurses’ judgement policies of risk assessments. Nurses’ judgement strategies also varied with the increased years of experience. Such variations in processing clinical information may contribute to nurses’ suboptimal judgements in clinical practice. Constructing predictive models of common judgement situations, and increasing nurses’ awareness of information weightings in such models may help improve judgements made by nurses.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0243-1) contains supplementary material, which is available to authorized users.

An early warning surveillance programme for detecting upper limb deterioration after treatment for breast cancer: A novel technology supported system

Upper limb morbidity is a well-recognised consequence of treatment for breast cancer that can develop for up to 6 years after treatment. However, the capacity to fully integrate evidence-based rehabilitation pathways into routine care for all patients is questionable due to limited resources. A long term surveillance programme must therefore be accessible to all patients, should identify those at risk of developing morbidity and target the interventions at the high risk population of patients. The proposed model uses a surrogate marker for assessing risk of morbidity, incorporated into an Early Warning System (EWS), to produce a technology-lead, prospective surveillance programme.

An early warning surveillance programme for detecting upper limb deterioration after treatment for breast cancer: A novel technology supported system

Upper limb morbidity is a well-recognised consequence of treatment for breast cancer that can develop for up to 6 years after treatment. However, the capacity to fully integrate evidence-based rehabilitation pathways into routine care for all patients is questionable due to limited resources. A long term surveillance programme must therefore be accessible to all patients, should identify those at risk of developing morbidity and target the interventions at the high risk population of patients. The proposed model uses a surrogate marker for assessing risk of morbidity, incorporated into an Early Warning System (EWS), to produce a technology-lead, prospective surveillance programme.

Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto

Rapid Response Systems have been introduced in the last decade to increase patient safety and decrease the rate of cardiorespiratory arrest on the hospital wards and readmission to the intensive care units. In this article we share our experience at the Hospital for Sick Children in Toronto on implementation and evolution of a pediatric rapid response team; the process, barriers, and ongoing challenges.

Evaluation of a configural vital signs display for intensive care unit nurses

OBJECTIVE

The objective was to evaluate a configural vital signs (CVS) display designed to support rapid detection and identification of physiological deterioration by graphically presenting patient vital signs data.

BACKGROUND

Current display technology in the intensive care unit (ICU) is not optimized for fast recognition and identification of physiological changes in patients. To support nurses more effectively, graphical or configural vital signs displays need to be developed and evaluated.

METHOD

A CVS display was developed based on findings from studies of the cognitive work of ICU nurses during patient monitoring. A total of 42 ICU nurses interpreted data presented either in a traditional, numerical format (n = 21) or on the CVS display (n = 21). Response time and accuracy in clinical data interpretation (i.e., identification of patient status) were assessed across four scenarios.

RESULTS

Data interpretation speed and accuracy improved significantly in the CVS display condition; for example, in one scenario nurses required only half of the time for data interpretation and showed up to 1.9 times higher accuracy in identifying the patient state compared to the numerical display condition.

CONCLUSION

Providing patient information in a configural display with readily visible trends and data variability can improve the speed and accuracy of data interpretation by ICU nurses.

APPLICATION

Although many studies, including this one, support the use of configural displays, the vast majority of ICU monitoring displays still present clinical data in numerical format. The introduction of configural displays in clinical monitoring has potential to improve patient safety.

The effect of improving task representativeness on capturing nurses' risk assessment judgements: a comparison of written case simulations and physical simulations

Background

The validity of studies describing clinicians’ judgements based on their responses to paper cases is questionable, because - commonly used - paper case simulations only partly reflect real clinical environments. In this study we test whether paper case simulations evoke similar risk assessment judgements to the more realistic simulated patients used in high fidelity physical simulations.

Methods

97 nurses (34 experienced nurses and 63 student nurses) made dichotomous assessments of risk of acute deterioration on the same 25 simulated scenarios in both paper case and physical simulation settings. Scenarios were generated from real patient cases. Measures of judgement ‘ecology’ were derived from the same case records. The relationship between nurses’ judgements, actual patient outcomes (i.e. ecological criteria), and patient characteristics were described using the methodology of judgement analysis. Logistic regression models were constructed to calculate Lens Model Equation parameters. Parameters were then compared between the modeled paper-case and physical-simulation judgements.

Results

Participants had significantly less achievement (r_a) judging physical simulations than when judging paper cases. They used less modelable knowledge (G) with physical simulations than with paper cases, while retaining similar cognitive control and consistency on repeated patients. Respiration rate, the most important cue for predicting patient risk in the ecological model, was weighted most heavily by participants.

Conclusions

To the extent that accuracy in judgement analysis studies is a function of task representativeness, improving task representativeness via high fidelity physical simulations resulted in lower judgement performance in risk assessments amongst nurses when compared to paper case simulations. Lens Model statistics could prove useful when comparing different options for the design of simulations used in clinical judgement analysis. The approach outlined may be of value to those designing and evaluating clinical simulations as part of education and training strategies aimed at improving clinical judgement and reasoning.

A before and after study assessing the impact of a new model for recognizing and responding to early signs of deterioration in an acute hospital

AIM

To evaluate the impact of a new model for the detection and management of deteriorating patients on knowledge and confidence of nursing staff in an acute hospital.

BACKGROUND

International evidence shows that clinical deterioration is not always recognized or acted on by nurses. The use of physiological track and trigger scoring systems accompanied by a graded response strategy has been recommended to monitor all adult patients in acute UK hospitals. However, little is known about the impact of these new systems in practice.

DESIGN

A single centre, mixed methods before-and-after study.

METHODS

A mixed methods before-and-after study, set in a district general hospital in England, in 2009, including a survey (n = 213) and qualitative interviews (n = 15) with nursing staff. The questionnaire examined knowledge and confidence in recognition and management of deteriorating patients 6 weeks before and after an intervention which included training, new observation charts and a new track and trigger system. Interviews further explored participants' perspectives. Comparisons were made between registered and unregistered nurses.

RESULTS

Following the intervention, knowledge, and confidence to recognize and manage deteriorating patients increased; the number of concerns were reduced. Scores were higher for registered than unregistered nurses before and after the intervention. Interviews confirmed these findings and provided detail on how nurses felt the new system had improved practice.

CONCLUSION

The new model had a positive impact on the self-assessed knowledge and confidence of registered and unregistered nurses. Similar initiatives should take into account the clinical context and tailor training packages accordingly.

How grounded theory can improve nursing care quality

This article presents an overview of the grounded theory research method and demonstrates how nurses can employ specific grounded theories to improve patient care quality. Because grounded theory is derived from real-world experience, it is a particularly appropriate method for nursing research. An overview of the method and language of grounded theory provides a background for nurses as they read grounded theories and apply newly acquired understandings to predictable processes and patterns of behavior. This article presents 2 exemplar grounded theories with suggestions as to how nurses can apply these and other grounded theories to improve the provision of quality nursing care.

Implementing the severe sepsis care bundles outside the ICU by outreach

Sepsis is not a new challenge facing the health care team, it remains a complex disease, which is difficult to identify and treat. Mortality from sepsis remains high and continues to be a common cause of death among critically ill patients, despite advances in critical care. Sepsis accounts for an estimated 27% of all intensive care admissions in England, Wales and Northern Ireland, and accounted for 46% of all intensive care bed days. Recent research studies and the surviving sepsis campaign have shown that identifying and providing key interventions to patients with severe sepsis and septic shock prior to their admission to the intensive care unit significantly improve outcomes. The aim of this paper was to identify how the Critical Care Outreach Team at one local hospital implemented the severe sepsis resuscitation care bundle for patients in the emergency department (ED) and on the general wards. It will include a presentation on the various ways the team raised the profile of severe sepsis and the care bundle at hospital and at national level. It also includes audit data that have been collected. The results showed that if the resuscitation care bundle was implemented within the first 24 h of hospital admission, mortality was 29%, whereas if the care bundle was instigated after this time mortality was more than at 49%. Audit data showed that the commonest sign of severe sepsis seen in patients in the ED and on wards was tachypnoea. This article discusses the successful implementation of the severe sepsis resuscitation care bundle and the positive impact an Outreach team can have in changing practice in the way patients are managed with severe sepsis. The audit data support the need for regular physiological observations and the use of a Patient At Risk Trigger scoring tool to identify patients at risk of deterioration. This allows referral to the Outreach team, who assess the patient and if appropriate initiate the care bundle.

Critical care outreach 1: an exploration of fundamental philosophy and underpinning knowledge

Critical care outreach (Outreach) is central to the effective management of critically ill patients. Its recent, expedited and somewhat uncoordinated introduction has, however, resulted in a lack of understanding about the fundamental philosophical theories and sources of knowledge that underpin it. Furthermore, there is a lack of understanding of the context in which these are applied. It is important that we understand and are able to provide sound rationale and guidance for current and future Outreach practice, for the education of practitioners and in order to evaluate and show the impact of Outreach on patient care. The need for this is heightened in the context of current changes in roles and role boundaries, in which there are significant pressures and expectations from organizations for Outreach teams to demonstrate their effectiveness. The authors argue that the complex situations encountered and managed by Outreach are not amenable to traditional forms of measurement and that its impact on patient care is, therefore, not readily acknowledged by those external to the service. This study explores the philosophical underpinnings and types of knowledge inherent in the practice of Outreach. In doing so, it illuminates how they apply and contribute to the practice and impact of Outreach.

Identifying level one patients. A cross-sectional survey on an in-patient hospital population

The purpose of this study was to identify the characteristics of level one patients and to explore how these differed from the other levels of care (zero and two). The study was conducted in two parts. Firstly, general adult in-patients (n=351) on the day of study were classified using the Intensive Care Society (ICS) Levels of Care. Secondly, a sample (n=67) of level zero, one and two patients were compared using physiological and demographic variables. Additionally, each patient was studied using three validated tools: EWS, TISS-28 and APACHE II. TISS-28 showed statistically significant results (p=0001) when correlated to level of care. When all three levels were analysed, EWS (p=0.001), APACHE II (p=0.0001) and variance in respiratory rate (p=0.001) showed significant differences in score according to level of care. However, no statistically significant differences were found between levels zero and one using the same data, allowing the deduction that ICS level two criteria are well defined and patients easily identifiable. The findings suggest that existing measurements of patient acuity, including the ICS criteria, are not sensitive enough to differentiate patients 'at risk' of deterioration (level one) from normal ward patients (level zero). This also suggests that level zero and one patients, based on the ICS classification, may not be from distinct populations but, in reality, one homogenous group.

Readmission to intensive care: A review of the literature

Acutely ill patients are commonly found on general hospital wards; some of these are patients who have been recently discharged from an intensive care unit (ICU). These patients may require a higher level of care than other ward patients and, due to the acuity of their illness, are at risk of readmission to ICU. Research has indicated that patients readmitted to ICU have mortality rates up to six times higher than those not readmitted and are eleven times more likely to die in hospital. Numerous studies have retrospectively examined these readmissions but, despite this, there is still no clear indication of why ICU readmissions occur or what the common characteristics of readmitted patients are. This literature review examines the published studies on patients who have been readmitted to ICU. Further research is needed to explore why readmissions to ICU occur and the type of patient who is at greatest risk for readmission.

Why don't nurses monitor the respiratory rates of patients?

Early warning systems (EWS) are being introduced to acute ward areas across the country to support the early recognition of patients at risk of developing a critical illness. All the systems are based on the monitoring of physiological observations of pulse, blood pressure, temperature, respirations and consciousness level. The main problem identified when attempting to introduce an early warning system to the acute general ward areas in one hospital was the general paucity of monitoring of patients observations by the nursing team. Respiratory rate was identified as the one parameter which nursing staff recorded less than 50% of the time. This qualitative study used focus groups in an attempt to understand the reasons behind the paucity in patient observation practice and explore the nurses' values and beliefs about patient monitoring within the context of care. The study identified four major factors associated with the paucity of patient monitoring: organization of nursing care activities, development of nursing observation skills, clinical decision making processes and equipment management issues.

Évaluation de la mise en place d'une formation continue du personnel de l'hôpital Bichat à la prise en charge des arrêts cardiocirculatoires intrahospitaliers

Management of in-hospital cardiac arrest is now considered as a hospital quality indicator. Such management actually requires training health care workers (HCWs) for basic life support (BLS).

OBJECTIVE

To assess the usefulness and efficacy of a short mandatory BLS training course amongst general ward HCWs in a 1,200 bed teaching hospital.

STUDY DESIGN

The in-hospital medical emergency team (MET) established a 45-min BLS training course comprising 10 goals for basic CPR and preparing for the arrival of the MET. Assessment was based on satisfaction questionnaires, cross-sectional evaluation of knowledge and skills of HCWs before and 1 year after the start of the training course. Efficacy of BLS performed on ward was assessed by the MET on scene.

RESULTS

One year after, 68 training sessions had been fulfilled and 522 HCWs had been trained (46.27% of total HCWs). HCWs were satisfied with the teaching course. Instant retention of objectives was over 90%. Cross-sectional surveys showed an improvement of BLS knowledge and skills. The knowledge of initial clinical assessment remained low. Knowledge and skills were significantly higher amongst HCWs who had been trained than amongst those who had not. Unfortunately, general ward BLS performance showed no improvement.

CONCLUSION

Short mandatory training courses are stimulating and well appreciated amongst HCWs. Although basic knowledge and skills improve dramatically, no improvement of on-scene BLS performance occurs.

Promoting care for acutely ill children-development and evaluation of a paediatric early warning tool

The primary purpose of this paper was to develop and evaluate a physiologically based system for the identification of acutely ill children in hospital environments. The dependency of children in hospital is increasing and ensuring the appropriate and timely intervention by a team of health personnel experienced in the care of these children is paramount to ensure their optimal outcome. A paediatric early warning (PEW) tool was designed and demographic and physiological data collected on all children (n = 360) who triggered the tool over a 6-month period, between September 2003 and February 2004. Analysis of the data was undertaken on each criterion within the tool and by reviewing it against patient outcome, the decision for its retention or removal was made. The modified tool showed a 99% sensitivity and a 66% specificity. The resultant Paediatric Early Warning Tool has been validated for use in a tertiary children's hospital in the United Kingdom (UK). The use of such a tool by all staff caring for acutely ill children in hospital environments can help to ensure their early recognition and timely treatment. The tool together with an action plan must, however, be appropriate for use in individual ward or hospital areas.

Beyond the intensive care unit: A review of interventions aimed at anticipating and preventing in-hospital cardiopulmonary arrest

Despite more than four decades of experience with in-hospital cardiopulmonary arrest, outcomes have remained poor. Numerous studies have documented the physiological instability leading to clinical deterioration, which often precedes cardiopulmonary arrest. These physiological changes often go unrecognized or are acted upon inadequately. This has led to the development of interventions aimed at anticipating and/or preventing cardiopulmonary arrest. In this review, we summarize the current literature regarding outcomes from in-hospital cardiopulmonary arrest, the physiological instability leading to clinical deterioration which often precedes cardiopulmonary arrest, and the various interventions to anticipate and prevent in-hospital cardiopulmonary arrest. These interventions include the use of intermediate care units, Modified Early Warning Scores (MEWS) and Medical Emergency Teams (MET). These interventions may have the potential to decrease the cardiac arrest rate and in-hospital mortality rate associated with cardiac arrest; however, controversy remains regarding some of these interventions. The use of intermediate care units may require an organized approach to identify patients who are acutely ill and would benefit from this specialized care. There is not enough evidence currently to support the benefit of Modified Early Warning Scores to prevent in-hospital cardiopulmonary arrest. Recent studies of the Medical Emergency Team have shown a significant decrease in cardiac arrest and overall mortality rates with this intervention. The Medical Emergency Team is an intervention, which requires further studies to define its role in other aspects of hospital patient care.

Exploring nursing roles: using physical assessment in the respiratory unit

The role of the nurse continues to change, with the point where nursing stops and medicine begins becoming increasingly blurred. Arguably, the main driver for this change could be the recent reduction in junior doctors' working hours. However, modern nursing is ripe for innovation and nurses are taking on more and more tasks and skills that were traditionally part of the doctor's remit. One example is physical assessment, which has very little evidence to support its use in any setting. Analysis of the utilization of physical assessment in the respiratory unit indicates that although it could facilitate earlier recognition of peri-arrest symptoms, its usage highlights training and legal issues. Furthermore, this article will explore whether the continual adoption of tasks, such as physical assessment, constitute mere role extension, with nurses becoming physicians' assistants rather than advanced autonomous practitioners.

Introducing an early warning scoring system in a district general hospital

One of the critical care outreach service's aims in this local hospital was to develop an assessment tool to help identify patients in danger of deterioration. This paper describes the introduction of an early warning scoring system between April 2001 and March 2002 to the surgical unit of a district general hospital. The informal and gradual approach used to optimize the effectiveness of introducing the early warning scoring system is highlighted. Explanations are given of the training processes undertaken, the pilot evaluation and lessons learned from the process. Using the experiences of the outreach service in introducing the early warning scoring system, this paper aims to provide thought for others considering a similar initiative in their area

The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team

AIM

(1) To identify risk factors for in-hospital cardiac arrest; (2) to formulate activation criteria to alert a clinical response culminating in attendance by a Medical Emergency Team (MET); (3) to evaluate the sensitivity and specificity of the scoring system.

METHODS

Quasi-experimental design to determine prevalence of risk factors for cardiac arrest in the hospitalised population. Weighting of risk factors and formulation of activation criteria to alert a graded clinical response. ROC analysis of weighted cumulative scores to determine their sensitivity and specificity.

SETTING

An acute 700 bed district general hospital with 32,348 adult admissions in 1999 and a catchment population of around 365,000.

SUBJECTS

118 consecutive adult patients suffering primary cardiac arrest in-hospital and 132 non-arrest patients, randomly selected according to stratified randomisation by gender and age.

RESULTS

Risk factors for cardiac arrest include: abnormal respiratory rate (P = 0.013), abnormal breathing indicator (abnormal rate or documented shortness of breath) (P < 0.001), abnormal pulse (P < 0.001), reduced systolic blood pressure (P < 0.001), abnormal temperature (P < 0.001), reduced pulse oximetry (P < 0.001), chest pain (P < 0.001) and nurse or doctor concern (P < 0.001). Multivariate analysis of cardiac arrest cases identified three positive associations for cardiac arrest: abnormal breathing indicator (OR 3.49; 95% CI: 1.69-7.21), abnormal pulse (OR 4.07; 95% CI: 2.0-8.31) and abnormal systolic blood pressure (OR 19.92; 95% CI: 9.48-41.84). Risk factors were weighted and tabulated. The aggregate score determines the grade of clinical response. ROC analysis determined that a score of 4 has 89% sensitivity and 77% specificity for cardiac arrest; a score of 8 has 52% sensitivity and 99% specificity. All patients scoring greater than 10 suffered cardiac arrest.

CONCLUSION

Risk factors for cardiac arrest have been identified, quantified and formulated into a table of activation criteria to help predict and avert cardiac arrest by alerting a clinical response. A graded clinical response has resulted in a tool that has both sensitivity and specificity for cardiac arrest.

Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital

AIMS

To determine the incidence of avoidable cardiac arrest among patients who had received resuscitation in a district general hospital. To establish how location and individual or system factors influence avoidable cardiac arrest in order to develop an evidence-based preventive strategy.

METHODS

Expert panel review of case-notes from 139 consecutive adult in-hospital cardiac arrests over 1 year.

RESULTS

There were 32,348 adult admissions in 1999 with 1,023 deaths. The cardiac arrest team was activated 139 times: 118 were for primary in-hospital cardiac arrest. The cardiac arrest rate excluding 'do not attempt resuscitation' (DNAR) cases was 3.8/1000 admissions. In 88.5% of deaths there was a DNAR policy. Survival to hospital discharge following resuscitation was 14%. Among the 118 cases, the panel unanimously agreed that 61.9% of arrests were potentially avoidable, rising to 68% when emergency department arrests were excluded (66 and 73% for majority opinion). Cardiac arrests were more likely at the weekend than during the week (P = 0.02). The odds of potentially avoidable cardiac arrest was 5.1 times greater for patients in general wards than critical care areas (P < 0.001); patients in critical care areas were more likely to survive (P < 0.001). The odds of potentially avoidable cardiac arrest was 12.6 times greater for patients nursed in a clinical area judged 'inappropriate' for their main complaint (P < 0.002, Fisher's exact test) compared to those nursed in 'appropriate' areas. The panel agreed that 100% of potentially avoidable arrests were judged to have received inadequate prior treatment. Clinical signs of deterioration in the preceding 24 h were not acted upon in 48%, and review was confined to a house officer in 45%.

CONCLUSION

The majority of treated in-hospital cardiac arrests are potentially avoidable. Multiple system failures include delays and errors in diagnosis, inadequate interpretation of investigations, incomplete treatment, inexperienced doctors and management in inappropriate clinical areas.

Critical care outreach services and early warning scoring systems: a review of the literature

AIM

The aim of this paper is to explore the literature relating to critical care outreach services and the use of early warning scoring systems to detect developing critical illness.

BACKGROUND

Several studies have identified how suboptimal care may contribute to physiological deterioration of patients with major consequences on morbidity, mortality and requirement for intensive care. In a review of adult critical care services, the Department of Health (DOH) (England) recommended in 2000 that outreach services be established to avert admissions to Intensive Care, to enable discharges and to share critical care skills.

METHODS

A literature search was carried out of the BIOMED and NESLI databases using the key words "outreach", "early warning signs/systems" and "suboptimal care". The literature review was limited to the past 10 years, and primary research articles of particular relevance were included in the review. The literature is examined within the context of recent findings relating to the provision of suboptimal care within general wards prior to cardiac arrest and/or admission to Intensive Care Units (ICU), and subsequent government initiatives. Discussion. The discussion explores the potential contribution of critical care outreach services and early warning scoring systems to the care of patients in acute general wards, including the role that education can have in developing the knowledge base and assessment skills of ward nurses.

CONCLUSION

The paper concludes that further study is required to evaluate the effectiveness of critical care outreach services and early warning scoring systems, and that ward staff need to be educated to identify those patients at risk of developing critical illness. Finally, it is suggested that nurses' decision-making in relation to calling the outreach team requires further investigation.