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Ede J, Kent B, Watkinson P, Endacott R. Successfully initiating an escalation of care in acute ward settings-A qualitative observational study. J Adv Nurs 2024. [PMID: 38934291 DOI: 10.1111/jan.16248] [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: 10/02/2023] [Revised: 05/03/2024] [Accepted: 05/09/2024] [Indexed: 06/28/2024]
Abstract
AIMS To address knowledge gaps by (i) developing a theoretical understanding of escalation and (ii) identifying escalation success factors. DESIGN Non-participant observations were used to examine deteriorating patient escalation events. METHODS Escalation event data were collected by a researcher who shadowed clinical staff, between February 16th 2021 and March 17th 2022 from two National Health Service Trusts. Events were analysed using Framework Analysis. Escalation tasks were mapped using a Hierarchical Task Analysis diagram and data presented as percentages, frequency and 95% CI. RESULTS A total of 38 observation sessions were conducted, totaling 105 h, during which 151 escalation events were captured. Half of these were not early warning score-initiated and resulted from bleeding, infection, or chest pain. Four communication phenotypes were observed in the escalation events. The most common was Outcome Focused Escalation, where the referrer expected specific outcomes like blood cultures or antibiotic prescriptions. Informative Escalations were often used when a triggering patient's condition was of low clinical concern and ranked as the second most frequent escalation communication type. General Concern Escalations occurred when the referrer did not have predetermined expectations. Spontaneous Interaction Escalations were the least frequently observed, occurring opportunistically in communal workspaces. CONCLUSION Half of the events were non-triggering escalations and understanding these can inform the design of systems to support staff better to undertake them. Escalation is not homogenous and differing escalation communication phenotypes exist. Informative Escalations represent an organizational requirement to report triggering warning scores and a targeted reduction of these may be organizationally advantageous. Increasing the frequency of Spontaneous Escalations, through hospital designs, may also be beneficial. IMPACT STATEMENT Our work highlights that a significant proportion of escalation workload occurs without a triggering early warning score and there is scope to better support these with designed systems. Further examination of reducing Informative and increasing Spontaneous Escalations is also warranted. PATIENT AND PUBLIC CONTRIBUTION Extensive PPIE was completed throughout the lifecycle of this study. PPIE members validated the research questions and overarching aims of the overall study. PPIE members contributed to the design of the study reviewed documents and the final data generated.
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Affiliation(s)
- J Ede
- Oxford University Hospital NHS Foundation Trust, Oxford, UK
- School of Nursing and Midwifery, University of Plymouth, Plymouth, UK
| | - B Kent
- School of Nursing and Midwifery, University of Plymouth, Plymouth, UK
| | - P Watkinson
- Oxford University Hospital NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - R Endacott
- School of Nursing and Midwifery, University of Plymouth, Plymouth, UK
- National Institute for Health and Care Research, Minerva House, London, UK
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Wei M, Huang M, Duan Y, Wang D, Xing X, Quan R, Zhang G, Liu K, Zhu B, Ye Y, Zhou D, Zhao J, Ma G, Jiang Z, Huang B, Xu S, Xiao Y, Zhang L, Wang H, Lin R, Ma S, Qiu Y, Wang C, Zheng Z, Sun N, Xian L, Li J, Zhang M, Guo Z, Tao Y, Zhang L, Zhou X, Chen W, Wang D, Chi J. Prognostic and risk factor analysis of cancer patients after unplanned ICU admission: a real-world multicenter study. Sci Rep 2023; 13:22340. [PMID: 38102299 PMCID: PMC10724261 DOI: 10.1038/s41598-023-49219-6] [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: 01/20/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023] Open
Abstract
To investigate the occurrence and 90-day mortality of cancer patients following unplanned admission to the intensive care unit (ICU), as well as to develop a risk prediction model for their 90-day prognosis. We prospectively analyzed data from cancer patients who were admitted to the ICU without prior planning within the past 7 days, specifically between May 12, 2021, and July 12, 2021. The patients were grouped based on their 90-day survival status, and the aim was to identify the risk factors influencing their survival status. A total of 1488 cases were included in the study, with an average age of 63.2 ± 12.4 years. The most common reason for ICU admission was sepsis (n = 940, 63.2%). During their ICU stay, 29.7% of patients required vasoactive drug support (n = 442), 39.8% needed invasive mechanical ventilation support (n = 592), and 82 patients (5.5%) received renal replacement therapy. We conducted a multivariate COX proportional hazards model analysis, which revealed that BMI and a history of hypertension were protective factors. On the other hand, antitumor treatment within the 3 months prior to admission, transfer from the emergency department, general ward, or external hospital, high APACHE score, diagnosis of shock and respiratory failure, receiving invasive ventilation, and experiencing acute kidney injury (AKI) were identified as risk factors for poor prognosis within 90 days after ICU admission. The average length of stay in the ICU was 4 days, while the hospital stay duration was 18 days. A total of 415 patients died within 90 days after ICU admission, resulting in a mortality rate of 27.9%. We selected 8 indicators to construct the predictive model, which demonstrated good discrimination and calibration. The prognosis of cancer patients who are unplanned transferred to the ICU is generally poor. Assessing the risk factors and developing a risk prediction model for these patients can play a significant role in evaluating their prognosis.
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Affiliation(s)
- Miao Wei
- Department of Intensive Care Unit, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, Shanxi, China
| | - Mingguang Huang
- Department of Intensive Care Unit, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, Shanxi, China.
| | - Yan Duan
- Department of Intensive Care Unit, Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, Shanxi, China
| | - Donghao Wang
- Department of Intensive Care Unit, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Xuezhong Xing
- Department of Intensive Care Unit, Cancer Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Rongxi Quan
- Department of Intensive Care Unit, Cancer Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang, China
| | - Guoxing Zhang
- Department of Intensive Care Unit, Gaoxin District of Jilin Cancer Hospital, Changchun, Jilin, China
| | - Kaizhong Liu
- Department of Intensive Care Unit, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, China
| | - Biao Zhu
- Department of Intensive Care Unit, Fudan University Affiliated Shanghai Cancer Hospital, Shanghai, China
| | - Yong Ye
- Department of Intensive Care Unit, Fujian Cancer Hospital and Fujian Medical University Cancer Hospital, Fuzhou, Fujian, China
| | - Dongmin Zhou
- Department of Intensive Care Unit, Henan Cancer Hospital, Zhengzhou, Henan, China
| | - Jianghong Zhao
- Department of Intensive Care Unit, Hunan Cancer Hospital, Changsha, Hunan, China
| | - Gang Ma
- Department of Intensive Care Unit, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, China
| | - Zhengying Jiang
- Department of Intensive Care Unit, Chongqing University Cancer Hospital, Chongqing, Sichuan, China
| | - Bing Huang
- Department of Intensive Care Unit, Guangxi Medical University Affiliated Tumor Hospital, Nanning, Guangxi, China
| | - Shanling Xu
- Department of Intensive Care Unit, Sichuan Cancer Hospital and Institute, Chengdu, Sichuan, China
| | - Yun Xiao
- Department of Intensive Care Unit, Yunnan Cancer Hospital, Kunming, Yunnan, China
| | - Linlin Zhang
- Department of Intensive Care Unit, Anhui Province Cancer Hospital, Hefei, Anhui, China
| | - Hongzhi Wang
- Department of Intensive Care Unit, Beijing Cancer Hospital, Beijing, China
| | - Ruiyun Lin
- Department of Intensive Care Unit, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Shuliang Ma
- Department of Intensive Care Unit, Jiangsu Cancer Hospital, Nanjing, Jiangsu, China
| | - Yu'an Qiu
- Department of Intensive Care Unit, Jiangxi Provincial Tumor Hospital, Nanchang, Jiangxi, China
| | - Changsong Wang
- Department of Intensive Care Unit, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Zhen Zheng
- Department of Intensive Care Unit, Liaoning Cancer Hospital and Institute, Shenyang, Liaoning, China
| | - Ni Sun
- Department of Intensive Care Unit, Huguang District of Jilin Cancer Hospital, Changchun, Jilin, China
| | - Lewu Xian
- Department of Intensive Care Unit, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ji Li
- Department of Intensive Care Unit, Hainan Cancer Hospital, Haikou, Hainan, China
| | - Ming Zhang
- Department of Intensive Care Unit, Hangzhou Cancer Hospital, Hangzhou, Zhejiang, China
| | - Zhijun Guo
- Department of Intensive Care Unit, Shandong First Medical University Affiliated Tumor Hospital, Jinan, Shandong, China
| | - Yong Tao
- Department of Intensive Care Unit, Nantong Tumor Hospital, Nantong, Jiangsu, China
| | - Li Zhang
- Department of Intensive Care Unit, Hubei Cancer Hospital, Wuhan, Hubei, China
| | - Xiangzhe Zhou
- Department of Intensive Care Unit, Gansu Provincial Cancer Hospital, Lanzhou, Gansu, China
| | - Wei Chen
- Department of Intensive Care Unit, Beijing Shijitan Hospital (Capital Medical University Cancer Hospital), Beijing, China
| | - Daoxie Wang
- Department of Intensive Care Unit, Cancer Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Jiyan Chi
- Department of Intensive Care Unit, Tumor Hospital of Mudanjiang City, Mudanjiang, Heilongjiang, China
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Kondos NA, Barrett J, McDonall J, Bucknall T. A Delphi study to obtain consensus on medical emergency team (MET) stand-down decision making. J Clin Nurs 2023; 32:7873-7882. [PMID: 37607900 DOI: 10.1111/jocn.16859] [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: 01/13/2023] [Revised: 07/15/2023] [Accepted: 08/10/2023] [Indexed: 08/24/2023]
Abstract
AIM A medical emergency team (MET) stand-down decision is the decision to end a MET response and hand responsibility for the patient back to ward staff for ongoing management. Little research has explored this decision. This study aimed to obtain expert consensus on the essential elements required to make optimal MET call stand-down decisions and the communication required before MET departure. DESIGN A Delphi design was utilised. METHODS An expert panel of 10 members were recruited based on their expert knowledge and recent clinical MET responder experience in acute hospital settings. Participants were emailed a consent form and an electronic interactive PDF for each survey. Two rounds were conducted with no attrition between rounds. The CREDES guidance on conducting and reporting Delphi studies was used to report this study. RESULTS Consensus by an expert panel of 10 MET responders generated essential elements of MET stand-down decisions. Essential elements comprised of two steps: (1) the stand-down decision that was influenced by both the patient situation and the ward/organisational context; and (2) the communication required before actioning stand-down. Communication after the decision required both verbal discussions and written documentation to hand over patient responsibility. Specific patient information, a management plan and an escalation plan were considered essential. CONCLUSION The Delphi surveys reached consensus on the actions and communication required to stand down a MET call. Passing responsibility back to ward staff after a MET call requires both patient and ward safety assessments, and a clearly articulated patient plan for ward staff. Observation of MET call stand-down decision-making is required to validate the essential elements. IMPLICATION FOR THE PROFESSION AND PATIENT/OR PATIENT CARE In specifying the essential elements, this study offers clinical and MET staff a process to support the handing over of clinical responsibility from the MET to the ward staff, and clarification of management plans in order to reduce repeat MET calls and improve patient outcomes. IMPACT Minimal research has been focussed on the decision to hand responsibility back to ward staff so the MET may leave the ward with safety plan in place. This study provided expert consensus to optimise MET stand-down decision-making and the ultimate decision to end a MET call. Communication of agreed patient treatment and escalation plans is recommended before leaving the ward. This study can be used as a checklist for MET responder staff making these decisions and ward staff responsible for post-MET call care. The aim being to reduce the likelihood of potentially preventable repeat deterioration in the MET patient population. REPORTING METHOD The CREDES guidance on conducting and reporting Delphi studies. PATIENT OR PUBLIC CONTRIBUTION None.
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Affiliation(s)
- Natalie A Kondos
- School of Nursing and Midwifery, Faculty of Health Deakin University, Victoria, Geelong, Australia
- Centre for Quality and Patient Safety Research - Alfred Health Partnership, Institute for Health Transformation, Deakin University, Victoria, Geelong, Australia
| | - Jonathan Barrett
- Centre for Quality and Patient Safety Research - Alfred Health Partnership, Institute for Health Transformation, Deakin University, Victoria, Geelong, Australia
| | - Jo McDonall
- School of Nursing and Midwifery, Faculty of Health Deakin University, Victoria, Geelong, Australia
| | - Tracey Bucknall
- School of Nursing and Midwifery, Faculty of Health Deakin University, Victoria, Geelong, Australia
- Centre for Quality and Patient Safety Research - Alfred Health Partnership, Institute for Health Transformation, Deakin University, Victoria, Geelong, Australia
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Batterbury A, Douglas C, Coyer F. The illness severity of ward remaining patients reviewed by the medical emergency team: A retrospective cohort study. J Clin Nurs 2023; 32:6450-6459. [PMID: 36894523 DOI: 10.1111/jocn.16678] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/14/2022] [Accepted: 02/20/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Although progress has been made in identifying and responding to acutely deteriorating ward patients, judgements about the level of care required for patients after medical emergency team review are complex, rarely including a formal assessment of illness severity. This challenges staff and resource management practices and patient safety. OBJECTIVE This study sought to quantify the illness severity of ward patients after medical emergency team review. RESEARCH DESIGN AND SETTING This retrospective cohort study examined the clinical records of 1500 randomly sampled adult ward patients following medical emergency team review at a metropolitan tertiary hospital. Outcome measures were the derivation of patient acuity and dependency scores using sequential organ failure assessment and nursing activities score instruments. Findings are reported using the STROBE guideline for cohort studies. NO PATIENT OR PUBLIC CONTRIBUTION No direct patient contact was made during the data collection and analysis phases of the study. RESULTS Patients were male (52.6%), unplanned (73.9%) medical admissions (57.5%), median age of 67 years. The median sequential organ failure assessment score was 4% and 20% of patients demonstrated multiple organ system failure requiring non typical monitoring and coordination arrangements for at least 24 h. The median nursing activities score was 86% suggestive of a near 1:1 nurse-to-patient ratio. More than half of all patients required enhanced levels of assistance with mobilization (58.8%) and hygiene (53.9%) activities. CONCLUSIONS Patients who remain on the ward following medical emergency team review had complex combinations of organ dysfunction, with levels of dependency similar to those found in intensive care units. This has implications for ward and patient safety and continuity of care arrangements. RELEVANCE TO CLINICAL PRACTICE Profiling illness severity at the conclusion of the medical emergency team review may help determine the need for special resource and staffing arrangements or placement within the ward environment.
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Affiliation(s)
- Anthony Batterbury
- Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Clint Douglas
- School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Fiona Coyer
- Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, Queensland, Australia
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Batterbury A, Douglas C, Jones L, Coyer F. Illness severity characteristics and outcomes of patients remaining on an acute ward following medical emergency team review: a latent profile analysis. BMJ Qual Saf 2023:bmjqs-2022-015637. [PMID: 36657785 DOI: 10.1136/bmjqs-2022-015637] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Patients requiring medical emergency team (MET) review have complex clinical needs, and most remain on the ward after review. Current detection instruments cannot identify post-MET patient requirements, meaning patients remain undistinguished, potentially resulting in missed management opportunities. We propose that deteriorating patients will cluster along dimensions of illness severity and that these clusters may be used to strengthen patient risk management practices. OBJECTIVE To identify and define the number of illness severity clusters and report outcomes among ward patients following MET review. STUDY DESIGN AND SETTING This retrospective cohort study examined the clinical records of 1500 adult ward patients following MET review at an Australian quaternary hospital. Three-step latent profile analysis methods were used to determine clusters using Sequential Organ Failure Assessment (SOFA) and Nursing Activities Score (NAS) as illness severity indicators. Study outcomes were (1) hospital mortality, (2) unplanned intensive care unit (ICU) admission and (3) subsequent MET review. RESULTS Patients were unplanned (73.9%) and medical (57.5%) admissions with at least one comorbidity (51.4%), and complex combinations of acuity (SOFA range 1-17) and dependency (NAS range 22.4%-148.5%). Five clusters are reported. Patients in cluster 1 were equivalent to clinically stable general ward patients. Organ failure and complexity increased with cluster progression-clusters 2 and 3 were equivalent to subspecialty/higher-dependency wards, and clusters 4 and 5 were equivalent to ICUs. Patients in cluster 5 had the greatest odds for death (OR 26.2, 95% CI 23.3 to 31.3), unplanned ICU admission (OR 3.1, 95% CI 3.0 to 3.1) and subsequent MET review (OR 2.4, 95% CI 2.4 to 2.6). CONCLUSION The five illness severity clusters may be used to define patients at risk of poorer outcomes who may benefit from enhanced levels of monitoring and targeted care.
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Affiliation(s)
- Anthony Batterbury
- Safety and Implementation Service, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia .,School of Nursing, Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Clint Douglas
- School of Nursing, Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia.,Office of Nursing and Midwifery Services, Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Lee Jones
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia.,Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Fiona Coyer
- School of Nursing, Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia.,Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Effect of a multi-faceted rapid response system re-design on repeat calling of the rapid response team. PLoS One 2022; 17:e0265485. [PMID: 35324935 PMCID: PMC8947019 DOI: 10.1371/journal.pone.0265485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 03/03/2022] [Indexed: 11/19/2022] Open
Abstract
Background Repeat Rapid Response Team (RRT) calls are associated with increased in-hospital mortality risk and pose an organisation-level resource burden. Use of Non-Technical Skills (NTS) at calls has the potential to reduce potentially preventable repeat calling. NTS are usually improved through training, although this consumes time and financial resources. Re-designing the Rapid Response System (RRS) to promote use of NTS may provide a feasible alternative. Methods A pre-post observational study was undertaken to assess the effect of an RRS re-design that aimed to promote use of NTS during RRT calls. The primary outcome was the proportion of admissions each month subject to repeat RRT calling, and the average number of repeat calls per admission each month was the secondary outcome of interest. Univariate and multivariable interrupted time series analyses compared outcomes between the two study phases. Results The proportion of admissions with repeat calls each month increased across both phases of the study period, but the increase was lower in the post re-design phase (change in regression slope -0.12 (standard error 0.07) post versus pre re-design). The multivariable model predicted a 6% reduction (95% confidence interval -15.1–3.1; P = 0.19) in the proportion of admissions having repeat calls at the end of the post redesign phase study compared to the predicted proportion in the absence of the re-design. The average number of calls per admission was also predicted to decrease in the post re-design phase, with an estimated difference of -0.07 calls per admission (equivalent to one fewer repeat call per 14 patients who had RRT calls) at the end of the post re-design phase (95% confidence interval -0.23–0.08, P = 0.35). Conclusion This study of an RRS re-design showed modest, but not statistically significant, reductions in the proportion of admissions with repeat calls and the mean number of repeat calls per admission. Given the economic and workforce capacity issues that all health care systems now face, even small improvements in the RRS may have lasting impact across the organisation. For the potential interest of RRS managers, this paper presents a pragmatic, low-cost initiative intended to enhance communication and cooperation at RRT calls.
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Lee JR, Jung YK, Hong SB, Huh JW. Predictors of Repeat Medical Emergency Team Activation in Deteriorating Ward Patients: A Retrospective Cohort Study. J Clin Med 2022; 11:1736. [PMID: 35330060 PMCID: PMC8950705 DOI: 10.3390/jcm11061736] [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: 02/03/2022] [Revised: 03/09/2022] [Accepted: 03/18/2022] [Indexed: 12/10/2022] Open
Abstract
Recurrent clinical deterioration and repeat medical emergency team (MET) activation are common and associated with high in-hospital mortality. This study assessed the predictors for repeat MET activation in deteriorating patients admitted to a general ward. We retrospectively analyzed the data of 5512 consecutive deteriorating hospitalized adult patients who required MET activation in the general ward. The patients were divided into two groups according to repeat MET activation. Multivariate logistic regression analyses were used to identify the predictors for repeat MET activation. Hematological malignancies (odds ratio, 2.07; 95% confidence interval, 1.54-2.79) and chronic lung disease (1.49; 1.07-2.06) were associated with a high risk of repeat MET activation. Among the causes for MET activation, respiratory distress (1.76; 1.19-2.60) increased the risk of repeat MET activation. A low oxygen saturation-to-fraction of inspired oxygen ratio (0.97; 0.95-0.98), high-flow nasal cannula oxygenation (4.52; 3.56-5.74), airway suctioning (4.63; 3.59-5.98), noninvasive mechanical ventilation (1.52; 1.07-2.68), and vasopressor support (1.76; 1.22-2.54) at first MET activation increased the risk of repeat MET activation. The risk factors identified in this study may be useful to identify patients at risk of repeat MET activation at the first MET activation. This would allow the classification of high-risk patients and the application of aggressive interventions to improve outcomes.
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Affiliation(s)
- Ju-Ry Lee
- Department of Nursing, Geoje University, 91, Majeon 1-gil, Geoje 53325, Korea;
| | - Youn-Kyung Jung
- Medical Emergency Team, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea;
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea;
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea;
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A Multicenter Cohort Study of Falls Among Patients Admitted to the ICU. Crit Care Med 2022; 50:810-818. [PMID: 34995212 DOI: 10.1097/ccm.0000000000005423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the incidence of falls, risk factors, and adverse outcomes, among patients admitted to the ICU. DESIGN Retrospective cohort study. SETTING Seventeen ICUs in Alberta, Canada. PATIENTS Seventy-three thousand four hundred ninety-five consecutive adult patient admissions between January 1, 2014, and December 31, 2019. MEASUREMENTS AND MAIN RESULTS A mixed-effects negative binomial regression model was used to examine risk factors associated with falls. Linear and logistic regression models were used to evaluate adverse outcomes. Six hundred forty patients experienced 710 falls over 398,223 patient days (incidence rate of 1.78 falls per 1,000 patient days [95% CI, 1.65-1.91]). The daily incidence of falls increased during the ICU stay (e.g., day 1 vs day 7; 0.51 vs 2.43 falls per 1,000 patient days) and varied significantly between ICUs (range, 0.37-4.64 falls per 1,000 patient days). Male sex (incidence rate ratio [IRR], 1.37; 95% CI, 1.15-1.63), previous invasive mechanical ventilation (IRR, 1.82; 95% CI, 1.40-2.38), previous sedative and analgesic medication infusions (IRR, 1.60; 95% CI, 1.15-2.24), delirium (IRR, 3.85; 95% CI, 3.23-4.58), and patient mobilization (IRR, 1.26; 95% CI, 1.21-1.30) were risk factors for falling. Falls were associated with longer ICU (ratio of means [RM], 3.10; 95% CI, 2.86-3.36) and hospital (RM, 2.21; 95% CI, 2.01-2.42) stays, but lower odds of death in the ICU (odds ratio [OR], 0.09; 95% CI, 0.05-0.17) and hospital (OR, 0.21; 95% CI, 0.14-0.30). CONCLUSIONS We observed that among ICU patients, falls occur frequently, vary substantially between ICUs, and are associated with modifiable risk factors, longer ICU and hospital stays, and lower risk of death. Our study suggests that fall prevention strategies should be considered for critically ill patients admitted to ICU.
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Albutt A, O’Hara J, Conner M, Lawton R. Can Routinely Collected, Patient-Reported Wellness Predict National Early Warning Scores? A Multilevel Modeling Approach. J Patient Saf 2021; 17:548-552. [PMID: 32084095 PMCID: PMC8612917 DOI: 10.1097/pts.0000000000000672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Measures exist to improve early recognition of and response to deteriorating patients in hospital. However, management of critical illness remains a problem globally; in the United Kingdom, 7% of the deaths reported to National Reporting and Learning System from acute hospitals in 2015 related to failure to recognize or respond to deterioration. The current study explored whether routinely recording patient-reported wellness is associated with objective measures of physiology to support early recognition of hospitalized deteriorating patients. METHODS A prospective observation study design was used. Nurses on four inpatient wards were invited to participate and record patient-reported wellness during every routine observation (where possible) using an electronic observation system. Linear multilevel modeling was used to examine the relationship between patient-reported wellness, and national early warning scores (NEWS), and whether patient-reported wellness predicted subsequent NEWS. RESULTS A significant positive relationship was found between patient-reported wellness and NEWS recorded at the next observation while controlling for baseline NEWS (β = 0.180, P = 0.033). A significant positive relationship between patient-reported wellness and NEWS (β = 0.229, P = 0.005) recorded during an observation 24 hours later while controlling for baseline NEWS was also found. Patient-reported wellness added to the predictive model for subsequent NEWS. CONCLUSIONS The preliminary findings suggest that patient-reported wellness may predict subsequent improvement or decline in their condition as indicated by objective measurements of physiology (NEWS). Routinely recording patient-reported wellness during observation shows promise for supporting the early recognition of clinical deterioration in practice, although confirmation in larger-scale studies is required.
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Affiliation(s)
- Abigail Albutt
- From the Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford Royal Infirmary
| | - Jane O’Hara
- From the Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford Royal Infirmary
- School of Medicine
| | - Mark Conner
- From the Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford Royal Infirmary
- School of Psychology, University of Leeds, Leeds, United Kingdom
| | - Rebecca Lawton
- School of Psychology, University of Leeds, Leeds, United Kingdom
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Byrne G, Ennis S, Barnes AM, Morrison P, Connors S, Quirke MB. Triggers and Interventions of Patients Who Require Medical Emergency Team Reviews: A Cross-Sectional Analysis of Single Versus Multiple Reviews. Crit Care Nurse 2021; 41:e1-e10. [PMID: 34333613 DOI: 10.4037/ccn2021407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Medical emergency teams constitute part of the escalation protocol of early warning systems in many hospitals. The literature indicates that medical emergency teams may reduce hospital mortality and cardiac arrest. A greater understanding of pathways of patients who experience multiple medical emergency team reviews will inform clinical decision-making. OBJECTIVES To explore differences between patients who require a single medical emergency team review and those who require multiple reviews, and to identify any differences between patients who were reviewed only once during admission and patients who required multiple reviews. METHODS Data for this retrospective cross-sectional review, including demographic data, call triggers, outcomes, and interventions, were routinely collected from January 2013 through December 2015. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) collaborative's cross-sectional studies checklist (version 4). RESULTS Of 54 787 admitted patients, 1274 (2%) required a call to a medical emergency team; of those, 260 patients (20%) needed multiple calls. Patients requiring multiple calls demonstrated higher mortality (odds ratio, 1.49 [95% CI, 1.12-1.98]). A logistic regression model identified surgical patients and those receiving antibiotics and respiratory interventions at the first medical emergency team review as being more likely to require multiple reviews. Patients transferred to a higher level of care after the first review were less likely to require another review. CONCLUSIONS Patients requiring multiple medical emergency team reviews have higher mortality. Surgical patients have a higher risk of requiring multiple reviews. Hospitals need to include more details on surgical patients when auditing medical emergency team activation.
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Affiliation(s)
- Gobnait Byrne
- Gobnait Byrne is Director, Trinity Centre for Practice and Health-care Innovation, and an assistant professor, School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Shauna Ennis
- Shauna Ennis is Head of Learning and Development, Tallaght University Hospital, Dublin, Ireland
| | - Anne Marie Barnes
- Anne Marie Barnes is the Emergency Response System Coordinator, Tallaght University Hospital
| | - Patricia Morrison
- Patricia Morrison is the Assistant Director of Nursing and Lead Assistant Director of Nursing for the Perioperative Directorate, Tallaght University Hospital
| | - Siobhan Connors
- Siobhan Connors is a critical care outreach nurse, Tallaght University Hospital
| | - Mary B Quirke
- Mary B. Quirke is a research fellow, Trinity Centre for Practice and Healthcare Innovation, School of Nursing and Midwifery, Trinity College Dublin
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11
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Na SJ, Ko RE, Ko MG, Koh A, Chung CR, Suh GY, Jeon K. Risk Factors for Early Medical Emergency Team Reactivation in Hospitalized Patients. Crit Care Med 2021; 48:e1029-e1037. [PMID: 32941188 DOI: 10.1097/ccm.0000000000004571] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this study was to investigate the risk factors for early medical emergency team reactivation (which is defined as repeated medical emergency team calls within 72 hr after the index medical emergency team call) in the patients remaining on the ward after index medical emergency team activation. DESIGN Retrospective analysis with prospectively collected data. SETTING A university-affiliated, tertiary referral hospital. PATIENTS All consecutive patients over 18 years old who received medical emergency team intervention. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 3,989 cases eligible for analysis, 514 cases (12.9%) were classified into the reactivation group, with the remainder assigned to the nonreactivation group. In a multivariate analysis, chronic lung disease (odds ratio, 1.38; 95% CI, 1.03-1.86; p = 0.032), chronic liver disease (odds ratio, 1.44; 95% CI, 1.04-1.99; p = 0.028), activation due to bedside concern about overall deterioration without abnormal physiological variables (odds ratio, 1.30; 95% CI, 1.00-1.68; p = 0.049), advice or consultation only for medical emergency team intervention (odds ratio, 0.78; 95% CI, 0.63-0.97; p = 0.027), and discussion about treatment limitation (odds ratio, 0.39; 95% CI, 0.25-0.60; p < 0.001) were independently associated with medical emergency team reactivation. In the reactivation group, 249 patients (48.5%) were transferred to the ICU after repeated calls. Medical department admission (odds ratio, 1.68; 95% CI, 1.12-2.52; p = 0.012), chronic liver disease (odds ratio, 1.73; 95% CI, 1.07-2.79; p = 0.025), hematological malignancies (odds ratio, 1.63; 95% CI, 1.10-2.41; p = 0.015), and tachypnea at the end of medical emergency team were risk factors for medical emergency team reactivation requiring ICU admission. Discussion about treatment limitation (odds ratio, 0.14; 95% CI, 0.05-0.40; p < 0.001) was also associated with decreased risk of medical emergency team reactivation requiring ICU admission. CONCLUSIONS An increased risk of early medical emergency team reactivation was associated with medical emergency team activation by bedside concern about overall deterioration and patients with chronic lung or liver disease.
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Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myeong Gyun Ko
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ahra Koh
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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12
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Impact of hospitalization duration before medical emergency team activation: A retrospective cohort study. PLoS One 2021; 16:e0247066. [PMID: 33606743 PMCID: PMC7894955 DOI: 10.1371/journal.pone.0247066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 01/31/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The rapid response system has been implemented in many hospitals worldwide and, reportedly, the timing of medical emergency team (MET) attendance in relation to the duration of hospitalization is associated with the mortality of MET patients. We evaluated the relationship between duration of hospitalization before MET activation and patient mortality. We compared cases of MET activation for early, intermediate, and late deterioration to patient characteristics, activation characteristics, and patient outcomes. We also aimed to determine the relationship, after adjusting for confounders, between the duration of hospitalization before MET activation and patient mortality. MATERIALS AND METHODS We retrospectively evaluated patients who triggered MET activation in general wards from March 2009 to February 2015 at the Asan Medical Center in Seoul. Patients were categorized as those with early deterioration (less than 2 days after admission), intermediate deterioration (2-7 days after admission), and late deterioration (more than 7 days after admission) and compared them to patient characteristics, activation characteristics, and patient outcomes. RESULTS Overall, 7114 patients were included. Of these, 1793 (25.2%) showed early deterioration, 2113 (29.7%) showed intermediate deterioration, and 3208 (45.1%) showed late deterioration. Etiologies of MET activation were similar among these groups. The clinical outcomes significantly differed among the groups (intensive care unit transfer: 34.1%, 35.6%, and 40.4%; p < 0.001 and mortality: 26.3%, 31.5%, and 41.2%; p < 0.001 for early, intermediate, and late deterioration, respectively). Compared with early deterioration and adjusted for confounders, the odds ratio of mortality for late deterioration was 1.68 (1.46-1.93). CONCLUSIONS Nearly 50% of the acute clinically-deteriorating patients who activated the MET had been hospitalized for more than 7 days. Furthermore, they presented with higher rates of mortality and ICU transfer than patients admitted for less than 7 days before MET activation and had mortality as an independent risk factor.
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13
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Batterbury A, Douglas C, Coyer F. The illness severity of patients reviewed by the medical emergency team: A scoping review. Aust Crit Care 2021; 34:496-509. [PMID: 33509705 DOI: 10.1016/j.aucc.2020.11.006] [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: 07/10/2020] [Revised: 11/16/2020] [Accepted: 11/22/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Medical emergency teams (METs) are internationally used to manage hospitalised deteriorating patients. Although triggers for MET review and hospital outcomes have previously been widely reported, the illness severity at the point of MET review has not been reported. As such, levels of clinical acuity and patient dependency representing the risk of exposure to short-term adverse clinical outcomes remain largely unknown. OBJECTIVE This scoping review sought to understand the illness severity of MET review recipients in terms of acuity and dependency. METHODS This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The published and grey literature since 2009 was searched to identify relevant articles reporting illness severity scores associated with hospitalised adult inpatients reviewed by a MET. After applying the inclusion and exclusion criteria, 17 articles (16 quantitative studies, one mixed-methods study) were reviewed, summarised, collated, and reported. RESULTS A total of 17 studies reported clinical acuity metrics for patients reviewed by a MET. No studies described an integrated risk score encompassing acuity, patient dependency, or wider parameters that might be associated with increased patient risk or the need for intervention. Multi-MET review, the use of specialist interventions, and delayed/transfer to the intensive care unit were associated with a greater risk of clinical deterioration, higher clinical acuity score, and predicted mortality risk. A single dependency metric was not reported although organisational levels of care, the duration of MET review, MET interventions, chronic illness, and frailty were inferred proxy measures. CONCLUSION Of the 17 studies reviewed, no single study provided an integrated assessment of illness severity from which to stratify risk or support patient management processes. Patients reviewed by a MET have variable and rapidly changing health needs that make them particularly vulnerable. The lack of high-quality data reporting acuity and dependency limits our understanding of true clinical risk and subsequent opportunities for pathway development.
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Affiliation(s)
- Anthony Batterbury
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia; School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia.
| | - Clint Douglas
- School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia; Metro North Hospital and Health Service, Herston, QLD, 4029, Australia.
| | - Fiona Coyer
- Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia; School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia.
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14
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Xiong Y, Dai W, Yu R, Liang L, Peng L. Physician awareness and attitudes regarding early warning score systems in mainland China: a cross-sectional study. Singapore Med J 2020; 63:162-166. [PMID: 32668838 DOI: 10.11622/smedj.2020107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The purpose of the study was to assess the application of the early warning score system (EWS-S) and gauge physician awareness, perceptions of necessity, and attitude regarding these tools based on previously experienced unnoticed clinical deterioration (CDET). METHODS A cross-sectional survey was carried out via an online questionnaire at a large 3,500-bed Class 3A general hospital in China. A total of 299 physicians of adult general wards were asked to answer a translated questionnaire that was localised from the original version. Demographic profiles were included as well as three other sections assessing awareness of CDET/EWS-S and gauging attitudes towards and perceptions of the necessity of EWS-S at our hospital. RESULTS There was a high level of physician awareness of the CDET problem. Most physicians knew about the existence of a systematic assessment tool for clinical application. Physicians with previous experience in reanimation, unplanned transfer to intensive care unit (UTICU) and/or death tended to consider EWS-S to be necessary in attentive and well-trained staff (p < 0.05). Physicians who had previous experience with UTICU were more likely to recommend implementing EWS-S in their wards compared with those without such experience (p < 0.05). CONCLUSION Most physicians have positive attitudes towards EWS-S. However, their awareness should be further heightened. Physicians who had previous experience with CDET/UTICU were more likely to employ EWS-S in their clinical practices. To better facilitate the implementation of EWS-S in Chinese hospitals, existing facilities, policy supports, standardised managements and the development of information systems should be strengthened.
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Affiliation(s)
- Yang Xiong
- Paediatric Ward, Xiangya Hospital, Central South University, Hunan, China
| | - Weiwei Dai
- Paediatric Ward, Xiangya Hospital, Central South University, Hunan, China
| | - Renhe Yu
- Xiangya School of Public Health, Central South University, Hunan, China
| | - Lingling Liang
- Orthopedics Department, the Sixth Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Lingli Peng
- Orthopedics Department, Xiangya Hospital, Central South University, Hunan, China
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15
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Hwang JI, Chin HJ. Relationships between the National Early Warning Score 2, clinical worry and patient outcome at discharge: Retrospective observational study. J Clin Nurs 2020; 29:3774-3789. [PMID: 32644226 DOI: 10.1111/jocn.15408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/19/2020] [Accepted: 06/27/2020] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES To examine the performance of the National Early Warning Score 2 and composite score for clinical worry in identifying patients at risk of clinical deterioration, and to determine relationships between National Early Warning Score 2, clinical worry score and patient outcome at discharge. BACKGROUND The efficacy of early warning systems depends on patient population and care settings. Based on a theoretical framework on factors affecting clinical deterioration and patient outcomes, studies exploring the relationship between early warning systems and patient outcomes at discharge are sparse. DESIGN Retrospective observational study. METHODS A random sample of 732 medical records were reviewed. The area under the receiver operating characteristic curve was calculated to evaluate predictive abilities regarding the events of unanticipated in-hospital mortality, unplanned intensive care unit/ higher dependency bed admission and cardiac arrest. Multiple logistic regression analyses were performed to determine relationships between National Early Warning Score 2, clinical worry score and patient outcome. Reporting followed the STROBE checklist. RESULTS National Early Warning Score 2 and clinical worry score significantly predicted the events within 24 hr of the assessment. After controlling for other patient, treatment and organisational characteristics, National Early Warning Score 2 was a significant factor associated with patient outcome, but clinical worry score was not. Specifically, patients at high risk based on National Early Warning Score 2 were less likely to have improved outcome. CONCLUSIONS National Early Warning Score 2 and clinical worry score performed well for predicting deteriorating condition of patients. National Early Warning Score 2 was significantly associated with patient outcome. It can be used for efficient patient management for safe, quality care. RELEVANCE TO CLINICAL PRACTICE National Early Warning Score 2 can be used for early assessment of not only clinical deterioration but also patient outcome and provide timely intervention, when coupled with clinical worry score.
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Affiliation(s)
- Jee-In Hwang
- College of Nursing Science, Kyung Hee University, Seoul, South Korea
| | - Ho Jun Chin
- Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam-Si, South Korea
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16
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Singh MY, Vegunta R, Karpe K, Rai S. Does the Time of Solitary Rapid Response Team Call Affect Patient Outcome? Indian J Crit Care Med 2020; 24:38-43. [PMID: 32148347 PMCID: PMC7050182 DOI: 10.5005/jp-journals-10071-23322] [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] [Indexed: 11/23/2022] Open
Abstract
Objective The study aimed to evaluate the effect of a single after-hours rapid response team (RRT) calls on patient outcome. Design A retrospective cohort study of RRT-call data over a 3-year period. Setting A 600-bedded, tertiary referral, public university hospital. Participants All adult patients who had a single RRT-call during their hospital stay. Intervention None. Main outcomes measures The primary outcome was to compare all-cause in-hospital mortality. The secondary outcomes were to study the hourly variation of RRT-calls and the mortality rate. Results Of the total 5,108 RRT-calls recorded, 1,916 patients had a single RRT-call. Eight hundred and sixty-one RRT-calls occurred during work-hours (08:00-17:59 hours) and 1,055 during after-hours (18:00-7:59). The all-cause in-hospital mortality was higher (15.07% vs 9.75%, OR 1.64, 95% CI 1.24-2.17, p value 0.001) in patients who had an after-hours RRT-call. This difference remained statistically significant after multivariate regression analysis (OR 1.50, 95% CI 1.11-2.01, p value 0.001). We noted a lower frequency of hourly RRT-calls after-hours but were associated with higher hourly mortality rates. There was no difference in outcomes for patients who were admitted to ICU post-RRT-call. Conclusion Patients having an after-hour RRT-call appear to have a higher risk for hospital mortality. No causal mechanism could be identified other than a decrease in hourly RRT usage during after-hours. How to cite this article Singh MY, Vegunta R, Karpe K, Rai S. Does the Time of Solitary Rapid Response Team Call Affect Patient Outcome? Indian J Crit Care Med 2020;24(1):38-43.
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Affiliation(s)
- Manoj Y Singh
- Department of Internal Medicine, Canberra Hospital, Canberra, Australia
| | - Ramprasad Vegunta
- Department of Internal Medicine, Canberra Hospital, Canberra, Australia
| | - Krishna Karpe
- Department of Internal Medicine, Canberra Hospital, Canberra, Australia
| | - Sumeet Rai
- Department of Internal Medicine, Canberra Hospital, Canberra, Australia
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17
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Albutt A, O'Hara J, Conner M, Lawton R. Involving patients in recognising clinical deterioration in hospital using the Patient Wellness Questionnaire: A mixed-methods study. J Res Nurs 2019; 25:68-86. [PMID: 34394609 DOI: 10.1177/1744987119867744] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Measures exist to improve early recognition of, and response to deteriorating patients in hospital. Despite these, 7% of the deaths reported to the National Reporting and Learning System from acute hospitals in 2015 related to a failure to recognise or respond to deterioration. Interventions have been developed that allow patients and relatives to escalate patient deterioration to a critical care outreach team. However, there is not a strong evidence base for the clinical effectiveness of these interventions, or patients' ability to recognise deterioration. Aims The aims of this study were as follows. (a) To identify methods of involving patients in recognising deterioration in hospital, generated by health professionals. (b) To develop and evaluate an identified method of patient involvement in practice, and explore its feasibility and acceptability from the perspectives of patients. Methods The study used a mixed-methods design. A measure to capture patient-reported wellness during observation was developed (Patient Wellness Questionnaire) through focus group discussion with health professionals and patients, and piloted on inpatient wards. Results There was limited uptake where patients were asked to record ratings of their wellness using the Patient Wellness Questionnaire themselves. However, where the researcher asked patients about their wellness using the Patient Wellness Questionnaire and recorded their responses during observation, this was acceptable to most patients. Conclusions This study has developed a measure that can be used to routinely collect patient-reported wellness during observation in hospital and may potentially improve early detection of deterioration.
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Affiliation(s)
- Abigail Albutt
- Research Fellow, Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Jane O'Hara
- Associate Professor in Patient Safety and Improvement Science, Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Mark Conner
- Professor of Applied Social Psychology, School of Psychology, University of Leeds, UK
| | - Rebecca Lawton
- Professor, Psychology of Healthcare, Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK.,School of Psychology, University of Leeds, UK
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18
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McKelvie BL, Lobos AT, Chan J, Momoli F, McNally JD. High Rate of Medical Emergency Team Activation in Children with Tracheostomy. J Pediatr Intensive Care 2019; 9:27-33. [PMID: 31984154 DOI: 10.1055/s-0039-1695733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/19/2019] [Indexed: 10/26/2022] Open
Abstract
Pediatric in-patients with tracheostomy (PIT) are at high risk for clinical deterioration. Medical emergency teams (MET) have been developed to identify high-risk patients. This study compared MET activation rates between PITs and the general ward population. This was a retrospective cohort study conducted at a tertiary pediatric hospital. The primary outcome (MET activation) was obtained from a database. Between 2008 and 2014, the MET activation rate was significantly higher in the PIT group than the general ward population (14 vs. 2.9 per 100 admissions, p < 0.001). PITs are at significantly higher risk for MET activation. Strategies should be developed to reduce their risk on the wards.
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Affiliation(s)
- Brianna L McKelvie
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, Western University, Children's Hospital-London Health Sciences Centre, London, Ontario, Canada
| | - Anna-Theresa Lobos
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Jason Chan
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Franco Momoli
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - James Dayre McNally
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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19
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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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20
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Allen J, Orellana L, Jones D, Considine J, Currey J. Associations between patient and system characteristics and MET review within 48 h of admission to a teaching hospital: A retrospective cohort study. Eur J Intern Med 2019; 66:62-68. [PMID: 31155230 DOI: 10.1016/j.ejim.2019.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/21/2019] [Accepted: 05/20/2019] [Indexed: 10/26/2022]
Abstract
The Medical Emergency Team (MET) has enhanced the recognition and response to clinical deterioration in acute healthcare. However, patients reviewed by the MET are at increased risk of in-hospital death. Identifying patients at risk of deterioration may improve patient outcomes. AIM: To identify patient demographic, medical characteristics and healthcare systems and processes at the time of admission (baseline), associated with Medical Emergency Team (MET) review within 48 h (MET-48 h) of admission. METHODS: Single-site, year-long, retrospective cohort comprising patients admitted for at least 24 h, using routinely collected hospital data. A three-stage modelling approach was used to identify baseline factors associated with MET-48 h RESULTS: The study included 15,695 patients with mean age 62.1 years (SD 19.6), male (53.5%), born in Australia or New Zealand (60.9%) and 51.6% held a low-income concession card. A total of 4.3% of patients received a MET review within 48 h of admission. Variables independently associated with MET-48 h in a fully adjusted logistic model included age of 80 years or more (OR = 1.37); ≥3 previous emergency admissions (OR = 1.59); Charlson Comorbidity Index 1 or 2 (OR = 1.47), or ≥ 3 (OR = 1.99); history of alcohol-related behaviour concerns (OR = 2.04), chronic heart failure (OR = 1.48); chronic obstructive pulmonary disease (OR = 1.35); admission for colorectal (OR = 2.66) or upper gastro-intestinal (OR = 1.94) surgery, respiratory or tracheostomy (OR = 2.24); immunology and infections (OR = 1.90); emergency admission (OR = 1.36); admission at night (OR = 1.74), or summer (OR = 1.41) CONCLUSIONS: This is the first study to demonstrate the potential to predict clinical deterioration using data that is readily accessible at the time of admission to hospital.
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Affiliation(s)
- Joshua Allen
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Geelong, VIC 3220, Australia.
| | - Liliana Orellana
- Deakin University, Biostatistics Unit, Faculty of Health, Geelong, VIC 3220, Australia.
| | - Daryl Jones
- DEPM Monash University, Level 6 The Alfred Centre (Alfred Hospital), 99 Commercial Road, Melbourne, Victoria 3004, Australia; Department of Surgery University of Melbourne, Austin Hospital, Studley Road Heidelberg, Victoria 3084, Australia; Intensive Care Unit, Austin Hospital, Studley Road Heidelberg, Victoria 3084, Australia.
| | - Julie Considine
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Geelong, VIC 3220, Australia; Centre for Quality and Patient Safety Research - Eastern Health Partnership, 2/5 Arnold Street, Box Hill, VIC 3128, Australia.
| | - Judy Currey
- Deakin University, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Geelong, VIC 3220, Australia.
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Chalwin R, Giles L, Salter A, Eaton V, Kapitola K, Karnon J. Reasons for Repeat Rapid Response Team Calls, and Associations with In-Hospital Mortality. Jt Comm J Qual Patient Saf 2018; 45:268-275. [PMID: 30522833 DOI: 10.1016/j.jcjq.2018.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/25/2018] [Accepted: 10/26/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous publications noted increased mortality risk in patients subject to repeat rapid response team (RRT) calls. These patients were examined as a homogenous group, but there may be many reasons for repeat calls. Those potentially preventable by the rapid response system have not been investigated. METHODS In a retrospective cohort study, patients with potentially preventable repeat calls were classified into two categories: type 1 (patients who had a repeat call following an initial call that ended despite the patient still triggering RRT calling criteria [T1-PRC]) and type 2 (patients with a repeat call within 24 hours of an initial call and for the same reason [T2-PRC]). In-hospital mortality for these patients and for those with repeat calls for all other reasons (ORC) were compared to patients with only a single call during their admission (SC). RESULTS Mortality occurred in 31 (43.7%) T1-PRC, 13 (15.1%) T2-PRC, 56 (28.9%) ORC, and 289 (13.9%) SC patients. Univariate odds ratios (ORs), in comparison to SC patients, were 4.81 (95% confidence interval [CI]: 2.96-7.81; p < 0.001), 1.10 (95% CI: 0.60-2.02; p = 0.75), and 2.52 (95% CI: 1.80-3.52; p < 0.001), respectively. Mortality effects persisted for the T1-PRC and ORC groups after adjustment for patient, admission, and initial call characteristics with ORs of 4.07 (95% CI: 2.36-7.01; p < 0.001) and 2.29 (95% CI: 1.57-3.34; p < 0.001), respectively. CONCLUSION This study found that repeat calls following an initial call that ended with ongoing breach of predefined calling criteria were strongly associated with increased mortality. This highlights the risk to patients when the RRT leaves reversible clinical deterioration unresolved at the end of a call.
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22
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Chalwin R, Flabouris A, Kapitola K, Dewick L. Perceptions of interactions between staff members calling, and those responding to, rapid response team activations for patient deterioration. AUST HEALTH REV 2018; 40:364-370. [PMID: 29224610 DOI: 10.1071/ah15138] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 09/07/2015] [Indexed: 12/21/2022]
Abstract
Objectives The aim of the present study was to investigate experiences of staff interactions and non-technical skills (NTS) at rapid response team (RRT) calls, and their association with repeat RRT calls. Methods Mixed-methods surveys were conducted of RRT members and staff who activate the RRT (RRT users) for their perceptions and attitudes regarding the use of NTS during RRT calls. Responses within the survey were recorded as Likert items, ranked data and free comments. The latter were coded into nodes relating to one of four NTS domains: leadership, communication, cooperation and planning. Results Two hundred and ninety-seven (32%) RRT users and 79 (73.8%) RRT members provided responses. Of the RRT user respondents, 76.5% had activated the RRT at some point. Deficits in NTS at RRT calls were revealed, with 36.9% of users not feeling involved during RRT calls and 24.7% of members perceiving that users were disinterested. Unresolved user clinical concerns, or persistence of RRT calling criteria, were reasons cited by 37.6% and 23%, respectively, of RRT users for reactivating an RRT to the same patient. Despite recollections of conflict at previous RRT calls, 92% of users would still reactivate the RRT. The most common theme in the free comments related to deficiencies in cooperation (52.9%), communication (28.6%) and leadership (14.3%). Conclusions This survey of RRT users and members revealed problems with RRT users' and members' interactions at the time of an RRT call. Both users and members considered NTS to be important, but lacking. These findings support NTS training for RRT members and users. What is known about the topic? Previous surveying has related experiences of criticism and conflict between clinical staff at RRT activations. This leads to reluctance to call the RRT when indicated, with risks to patient safety, especially if subsequent RRT activation is necessary. Training in NTS has improved clinician interactions in simulated emergencies, but the exact role of NTS during RRT calls has not yet been established. What does this paper add? The present survey examined experienced clinicians' perceptions of the use of NTS at RRT calls and the effect on subsequent calling. A key finding was a disparity between perceptions of how RRT members interact with those activating the RRT (RRT users) and their performance of NTS. This was reflected with unresolved RRT user clinical concern at the time of a call. In turn, this affected RRT users' attitudes and intentions to reactivate the RRT. Formal handover was considered desirable by both RRT users and members. What are the implications for practitioners? The interface between the RRT and those who call the RRT is crucial. This survey shows that RRT users desire to be included in the management of the deteriorating patient and have their concerns addressed before completion of RRT attendance. Failure to do so results in repeat activations to the same patient, with the potential for adverse patient outcomes. Training to include NTS, especially around handover, for RRT members may address this issue and should be explored further.
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Affiliation(s)
- Richard Chalwin
- Intensive Care Unit, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5112, Australia
| | - Arthas Flabouris
- Discipline of Acute Care Medicine, School of Medicine, Faculty of Health Sciences, University of Adelaide, SA 5005, Australia
| | - Karoline Kapitola
- IMPACT Project, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5112, Australia.
| | - Leonie Dewick
- IMPACT Project, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5112, Australia.
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Montgomery HE, Haines A, Marlow N, Pearson G, Mythen MG, Grocott MPW, Swanton C. The future of UK healthcare: problems and potential solutions to a system in crisis. Ann Oncol 2018; 28:1751-1755. [PMID: 28453610 DOI: 10.1093/annonc/mdx136] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The UK's Health System is in crisis, central funding no longer keeping pace with demand. Traditional responses-spending more, seeking efficiency savings or invoking market forces-are not solutions. The health of our nation demands urgent delivery of a radical new model, negotiated openly between public, policymakers and healthcare professionals. Such a model could focus on disease prevention, modifying health behaviour and implementing change in public policy in fields traditionally considered unrelated to health such as transport, food and advertising. The true cost-effectiveness of healthcare interventions must be balanced against the opportunity cost of their implementation, bolstering the central role of NICE in such decisions. Without such action, the prognosis for our healthcare system-and for the health of the individuals it serves-may be poor. Here, we explore such a new prescription for our national health.
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Affiliation(s)
- H E Montgomery
- Department of Medicine, University College London, London
| | - A Haines
- Departments of Social and Environmental Health Research and of Population Health, London.,School of Hygiene and Tropical Medicine, London
| | - N Marlow
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, London
| | - G Pearson
- Department of Paediatric Intensive Care, Birmingham Children's Hospital, Birmingham
| | - M G Mythen
- Department of Anaesthesia and Critical Care, University College London, London
| | - M P W Grocott
- Department of Anaesthesia and Critical Care, University Hospitals Southampton NHS Foundation Trust and University of Southampton, Southampton
| | - C Swanton
- UCL Cancer Institute, CRUK Lung Cancer Centre of Excellence, London, UK
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Fernando SM, Reardon PM, Scales DC, Murphy K, Tanuseputro P, Heyland DK, Kyeremanteng K. Prevalence, Risk Factors, and Clinical Consequences of Recurrent Activation of a Rapid Response Team: A Multicenter Observational Study. J Intensive Care Med 2018; 34:782-789. [PMID: 29720053 DOI: 10.1177/0885066618773735] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Rapid response teams (RRTs) are groups of health-care providers, implemented by hospitals to respond to distressed hospitalized patients on the hospital wards. Patients assessed by the RRT for deterioration may be admitted to the intensive care unit (ICU) or may be triaged to remain on the wards, putting them at risk of recurrent deterioration and repeat RRT activation. Previous studies evaluating outcomes of patients with recurrent deterioration and multiple RRT activations have produced conflicting results. METHODS We used a prospectively collected multicenter registry from 2 hospitals within a single tertiary-level hospital system between 2012 and 2016. Comparisons were made between patients with a single RRT activation and those with multiple RRT activations over the course of their admission. Primary outcome was in-hospital mortality, which was analyzed using multivariable logistic regression. RESULTS A total of 5995 patients who had any RRT activation were analyzed. Of that, 1183 (19.7%) patients had recurrent deterioration and multiple RRT activations during their admission. Risk factors for recurrent deterioration included admission from a home setting (as opposed to a long-term care facility), RRT activation during nighttime hours, and delay (>1 hour) to RRT activation. Recurrent deterioration was associated with increased odds of mortality (adjusted odds ratio [OR]: 1.44 [1.28-1.64], P = <.001). Increasing number of RRT activations were associated with increasing risk of mortality. Patients with recurrent deterioration had prolonged median hospital length of stay (21.0 days vs 12.0 days, P < .001), while patients with only a single activation were more likely to be admitted to the ICU (adjusted OR: 2.30 [1.96-2.70], P < .001). CONCLUSIONS Recurrent deteriorations leading to RRT activations among hospitalized patients are associated with increased odds of mortality and prolonged hospital length of stay. This work identifies a group of patients who warrant closer attention to help reduce adverse outcomes.
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Affiliation(s)
- Shannon M Fernando
- 1 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,2 Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter M Reardon
- 1 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,2 Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Damon C Scales
- 3 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,4 Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Kyle Murphy
- 1 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- 5 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,6 Bruyere Research Institute, Ottawa, Ontario, Canada.,7 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daren K Heyland
- 8 Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Kwadwo Kyeremanteng
- 1 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,5 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,7 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Abstract
OBJECTIVE We describe the characteristics and outcomes of pediatric repeat rapid response events within a single hospitalization. We hypothesized that triggers for repeat rapid response and initial rapid response events are similar, and repeat rapid response events are associated with high prevalence of medical complexity and worse outcomes. DESIGN A 3-year retrospective study. SETTING High-volume tertiary academic pediatric hospital. PATIENTS All rapid response events were reviewed to identify repeat rapid response events. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Patient demographics, rapid response triggers, primary clinical diagnoses, illness acuity scores, medical interventions, transfers to ICU, occurrence of critical deterioration, and mortality were reviewed. We reviewed 146 patients with 309 rapid response events (146 initial rapid response and 163 repeat rapid response: 36% < 24 hr, 38% 24 hr to 7 d, and 26% > 7 d after initial rapid response). Median age was 3 years, and 60% were males. Eighty-five percentage of repeat rapid response occurred in medical complexity patients. The triggers for 71% of all repeat rapid response matched with those of initial rapid response. Transfer to ICU occurred in 69 (47%) of initial rapid response and 124 (76%) of repeat rapid response (p < 0.01). The median hospital stay was 11 and 30 days for previously healthy and medical complexity patients, respectively (p = 0.16). ICU readmission at repeat rapid response was associated with longer hospital stay (p < 0.01). Mortality during hospitalization occurred in 14% (all medically complex) of patients after repeat rapid response. Hospital mortality after rapid response is 4.4% per our center's administrative data and 6.7% according to published multicenter data. CONCLUSIONS Prevalence of medical complexity was high in patients with repeat rapid response compared with that reported for pediatric hospitalizations. Triggers between initial and repeat rapid response events correlated. Transfer to ICU was more likely after repeat rapid response and among repeat rapid response, events with ICU readmissions had a longer length of ICU and hospital stay. Mortality for the repeat rapid response cohort was higher than that for overall rapid responses in our center and per published reports from other centers.
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26
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Padilla RM, Mayo AM. Clinical deterioration: A concept analysis. J Clin Nurs 2018; 27:1360-1368. [PMID: 29266536 DOI: 10.1111/jocn.14238] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2017] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To present a concept analysis of clinical deterioration and introduce an operational definition. BACKGROUND Hospitalised patients who endure cardiopulmonary arrest and unplanned intensive care unit admissions often exhibit physiological signs preceding these events. Clinical deterioration not promptly recognised can result in increased patient morbidity and mortality. A barrier to recognising and responding to clinical deterioration stems from practice variations among healthcare clinicians. DESIGN Concept analysis. METHODS Eight-step method of concept analysis proposed by Walker and Avant. RESULTS Defining attributes include dynamic state, decompensation and objective and subjective determination. Antecedents identified include clinical state, susceptibility, pathogenesis and adverse event. Increased mortality, resuscitation, implementation of higher level of care and prolonged hospital admission were the consequences identified. Defining attributes, antecedents and consequences identified led to an operational definition of clinical deterioration as a dynamic state experienced by a patient compromising hemodynamic stability, marked by physiological decompensation accompanied by subjective or objective findings. CONCLUSIONS Clinical deterioration is a key contributor to inpatient mortality, and its recognition is often underpinned by contextual factors and practice variances. Variation in the uniformity of the concept of clinical deterioration causes a gap in knowledge and necessitated clarification of this phenomenon for nursing research and practice. RELEVANCE TO CLINICAL PRACTICE Identifying and intervening on clinical deterioration plays a vital role in the inpatient setting demonstrated by the dynamic nature of a patients' condition during hospitalisation. It is anticipated that this concept analysis on clinical deterioration will contribute to further identification of clinically modifiable risk factors and accompanying interventions to prevent clinical deterioration in the inpatient setting.
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Affiliation(s)
- Ricardo M Padilla
- Hahn School of Nursing & Health Science, Beyster Institute for Nursing Research, University of San Diego, San Diego, CA, USA
| | - Ann M Mayo
- Hahn School of Nursing & Health Science, Beyster Institute for Nursing Research, University of San Diego, San Diego, CA, USA
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Allen J, Jones D, Currey J. Clinician and manager perceptions of factors leading to ward patient clinical deterioration. Aust Crit Care 2017; 31:369-375. [PMID: 29153825 DOI: 10.1016/j.aucc.2017.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/20/2017] [Accepted: 09/22/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Improving the timely recognition and response to clinical deterioration is a critical challenge for clinicians, educators, administrators and researchers. Clinical deterioration leading to Rapid Response Team review is associated with poor patient outcomes. A range of factors associated with clinical deterioration and its outcomes have been identified, and may help with early identification of deteriorating patients. However, the relative importance of each factor on the development of clinical deterioration is unknown. OBJECTIVE To identify the relative importance of factors contributing to the development of clinical deterioration in ward patients, as perceived by health professionals who have experience in recognising or responding to clinical deterioration, or in the management, administration or governance of RRSs. METHODS A written questionnaire containing 12 pre-determined factors was provided to participants. Participants were asked to rank the items from most to least important contributors to ward patient deterioration. The study took place during a session of the Australia and New Zealand Intensive Care Society Rapid Response Team conference. RESULTS A final sample of 233 (83% response rate), returned the questionnaire. The sample comprised specialist ICU registered nurses with direct patient contact (64%), ICU consultant doctors (17%), ICU nurse managers (7%), hospital administrators (2%), ICU registrars (2%), quality coordinators (2%) and non-hospital staff (4%). The patient's presenting illness/main diagnosis was the highest ranked factor, followed by pre-existing co-morbidities, seniority of nursing ward staff, medical documentation, senior medical staff, and interdisciplinary communication. Almost two-thirds of participants ranked patient characteristics as the most important contributor to clinical deterioration. CONCLUSION Health professionals who have experience in recognising or responding to clinical deterioration, or in the management, administration or governance of RRSs perceive that patient characteristics such as the patient's primary diagnosis and comorbidities to be the most important contributors to clinical deterioration.
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Affiliation(s)
- Joshua Allen
- Deakin University, Geelong, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Victoria 3125, Australia.
| | - Daryl Jones
- DEPM Monash University, Level 6 The Alfred Centre (Alfred Hospital), 99 Commercial Road, Melbourne, Victoria 3004, Australia; Department of Surgery, University of Melbourne, Parkville, Victoria 3010, Australia; Intensive Care Unit, Austin Hospital, Studley Road Heidelberg, Victoria 3084, Australia.
| | - Judy Currey
- Deakin University, Geelong, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Victoria 3125, Australia.
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Patient physiological status during emergency care and rapid response team or cardiac arrest team activation during early hospital admission. Eur J Emerg Med 2017; 24:359-365. [DOI: 10.1097/mej.0000000000000375] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Albutt AK, O'Hara JK, Conner MT, Fletcher SJ, Lawton RJ. Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review. Health Expect 2017; 20:818-825. [PMID: 27785868 PMCID: PMC5600219 DOI: 10.1111/hex.12496] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Measures exist to improve early recognition of, and response to, deteriorating patients in hospital. However, deteriorating patients continue to go unrecognized. To address this, interventions have been developed that invite patients and relatives to escalate patient deterioration to a rapid response team (RRT). OBJECTIVE To systematically review articles that describe these interventions and investigate their effectiveness at reducing preventable deterioration. SEARCH STRATEGY Following PRISMA guidelines, four electronic databases and two web search engines were searched to identify literature investigating patient and relative led escalation. INCLUSION CRITERIA Articles investigating the implementation or use of systems involving patients and relatives in the detection of clinical patient deterioration and escalation of patient care to address any clinical or non-clinical outcomes were included. Articles' eligibility was validated by a second reviewer (20%). DATA EXTRACTION Data were extracted according to pre-defined criteria. DATA SYNTHESIS Narrative synthesis was applied to included studies. MAIN RESULTS Nine empirical studies and 36 grey literature articles were included in the review. Limited studies were conducted to establish the clinical effectiveness of patient and relative led escalation. Instead, studies investigated the impact of this intervention on health-care staff and available resources. Although appropriate, this reflects the infancy of research in this area. Patients and relatives did not overwhelm resources by activating the RRT. However, they did activate it to address concerns unrelated to patient deterioration. CONCLUSIONS Activating a RRT may not be the most appropriate or cost-effective method of resolving non-life-threatening concerns.
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Affiliation(s)
- Abigail K. Albutt
- School of PsychologyUniversity of LeedsLeedsUK
- Bradford Institute for Health ResearchBradford Royal InfirmaryBradfordUK
| | - Jane K. O'Hara
- School of MedicineUniversity of LeedsLeedsUK
- Bradford Institute for Health ResearchBradford Royal InfirmaryBradfordUK
| | | | | | - Rebecca J. Lawton
- School of PsychologyUniversity of LeedsLeedsUK
- Bradford Institute for Health ResearchBradford Royal InfirmaryBradfordUK
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Increased Mortality and Length of Stay Associated With Medical Emergency Team Review in Hospitalized Pediatric Patients: A Retrospective Cohort Study. Pediatr Crit Care Med 2017; 18:571-579. [PMID: 28445242 DOI: 10.1097/pcc.0000000000001164] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Rapid response systems using medical emergency teams reduce hospital wide cardiorespiratory arrest and mortality. While rapid response systems improve hospital-wide outcomes, children receiving medical emergency team review may still be at increased risk for morbidity and mortality. The study purpose was to compare the length of stay and mortality rate in children receiving a medical emergency team review with those of other hospitalized children. DESIGN Retrospective cohort study. SETTING Tertiary Pediatric Hospital, Children's Hospital of Eastern Ontario, Ottawa, Canada. PATIENTS Cohort of 42,308 pediatric admissions to the general inpatient ward. INTERVENTIONS Data over 7 years were obtained from a prospectively maintained rapid response systems database. MEASUREMENTS AND MAIN RESULTS From the cohort, 995 (2.35%) of the admissions had one and 276 (0.65%) had multiple medical emergency team activations. When compared with patients without, children having one or multiple medical emergency team reviews had 13.34 (95% CI, 5.33-33.2) and 50.10 (95% CI, 19.86-126.39) times the odds of death, respectively. Patients experiencing a medical emergency team review stayed in hospital 1.59 times (95% CI, 1.39-1.82) longer, whereas those with multiple medical emergency team reviews stayed 2.44 times (95% CI, 1.85-3.20) longer. The associations remained significant after controlling for important confounders and excluding elective admissions from the analyses. Most repeat medical emergency team reviews occurred within a day of the initial review or involved patients with multiple comorbidities. CONCLUSIONS Our study suggests that pediatric patients reviewed by the medical emergency team are at significantly higher risk of mortality and longer length of stay than general ward inpatients. As well, patients with multiple medical emergency team reviews were at particularly high risk compared with patients with one medical emergency team review. Patients who experience medical emergency team reviews should be recognized as a high-risk group, and future studies should consider how to decrease morbidity and mortality. Based on our findings, we suggest that these patients be followed for 24-48 hours after any medical emergency team activation.
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Malycha J, Bonnici T, Sebekova K, Petrinic T, Young D, Watkinson P. Variables associated with unplanned general adult ICU admission in hospitalised patients: protocol for a systematic review. Syst Rev 2017; 6:67. [PMID: 28351424 PMCID: PMC5370455 DOI: 10.1186/s13643-017-0456-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 03/14/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Failure to promptly identify deterioration in hospitalised patients is associated with delayed admission to intensive care units (ICUs) and poor outcomes. Existing vital sign-based Early Warning Score (EWS) algorithms do not have a sufficiently high positive predictive value to be used for automated activation of an ICU outreach team. Incorporating additional patient data might improve the predictive power of EWS algorithms; however, it is currently not known which patient data (or variables) are most predictive of ICU admission. We describe the protocol for a systematic review of variables associated with ICU admission. METHODS/DESIGN MEDLINE, EMBASE, CINAHL and the Cochrane Library, including Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL) will be searched for studies that assess the association of routinely recorded variables associated with subsequent unplanned ICU admission. Only studies involving adult patients admitted to general ICUs will be included. We will extract data relating to the statistical association between ICU admission and predictor variables, the quality of the studies and the generalisability of the findings. DISCUSSION The results of this review will aid the development of future models which predict the risk of unplanned ICU admission. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42015029617.
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Affiliation(s)
- James Malycha
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Level 3, Headley Way, Oxford, OX3 9DU UK
| | - Tim Bonnici
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Level 3, Headley Way, Oxford, OX3 9DU UK
| | - Katarina Sebekova
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Level 3, Headley Way, Oxford, OX3 9DU UK
| | - Tatjana Petrinic
- University of Oxford, Bodleian Health Care Libraries, Academic Centre, John Radcliffe Hospital, Level 3, Headley Way, Oxford, OX3 9DU UK
| | - Duncan Young
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Level 3, Headley Way, Oxford, OX3 9DU UK
| | - Peter Watkinson
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Level 3, Headley Way, Oxford, OX3 9DU UK
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Sen S, Acash G, Sarwar A, Lei Y, Dargin JM. Utility and diagnostic accuracy of bedside lung ultrasonography during medical emergency team (MET) activations for respiratory deterioration. J Crit Care 2017; 40:58-62. [PMID: 28342384 DOI: 10.1016/j.jcrc.2017.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/16/2017] [Accepted: 03/09/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE We investigated the feasibility and diagnostic accuracy of lung ultrasonography during medical emergency team (MET) activations for respiratory deterioration. MATERIAL AND METHODS We performed a prospective study of inpatients requiring MET evaluation for respiratory decompensation. A blinded investigator recorded videos of lung and lower extremity ultrasonography. The videos were reviewed by blinded investigators to determine a ultrasonography diagnosis. The accuracy of MET diagnosis and ultrasonography diagnosis were compared to the final diagnosis determined by retrospective chart review. RESULTS The ultrasound exam was completed in 49/50 (98%) patients enrolled in the study with a mean duration of 13±4min. When excluding six cases that were not amenable to diagnosis by our algorithm, we report a lung ultrasonography diagnostic accuracy of 84% (37/44) which is similar to the accuracy of the MET clinical diagnosis of 75% (33/44) (p=0.29). Furthermore, we report in 28/37 (76%) of cases where the lung ultrasonography diagnosis was correct, patients may have received inappropriate therapies. CONCLUSIONS Lung ultrasonography can be rapidly performed in the majority of patients with MET activation for respiratory deterioration. As an independent diagnostic test, lung ultrasonography is non-inferior to the MET clinical assessment and may prevent unnecessary treatments if used simultaneously.
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Affiliation(s)
- Soumitra Sen
- Lahey Hospital and Medical Center, Department of Pulmonary and Critical Care Medicine, Tufts University School of Medicine, United States.
| | - Ghazwan Acash
- Lahey Hospital and Medical Center, Department of Pulmonary and Critical Care Medicine, Tufts University School of Medicine, United States
| | - Akmal Sarwar
- Lahey Hospital and Medical Center, Department of Pulmonary and Critical Care Medicine, Tufts University School of Medicine, United States
| | - Yuxiu Lei
- Lahey Hospital and Medical Center, Department of Pulmonary and Critical Care Medicine, Tufts University School of Medicine, United States
| | - James M Dargin
- Lahey Hospital and Medical Center, Department of Pulmonary and Critical Care Medicine, Tufts University School of Medicine, United States
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Bellew SD, Cabrera D, Lohse CM, Bellolio MF. Predicting Early Rapid Response Team Activation in Patients Admitted From the Emergency Department: The PeRRT Score. Acad Emerg Med 2017; 24:216-225. [PMID: 27611487 DOI: 10.1111/acem.13077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/25/2016] [Accepted: 08/28/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Rapid response teams (RRTs) respond to signs of deterioration to avoid morbidity and mortality. Early RRT activation (eRRT) in patients admitted from the emergency department (ED) is associated with significantly increased mortality. Predicting these events may represent an opportunity to identify patients who would benefit from further resuscitation, aid disposition decision-making, or improve communication between ED and inpatient providers. We aimed to create a clinical prediction instrument to quantify the risk of eRRT. METHODS We performed an observational cohort study of patients admitted to a non-intensive care unit (ICU) setting who triggered eRRT from January 2009 to December of 2012 compared to those who did not trigger eRRT. Age, sex, ED vital sign measurements, and final ED diagnosis by ICD-9 code were evaluated in a multivariable logistic regression model. The performance of prediction models was assessed using discrimination summarized by area under a receiver operating curve (AUC) and calibration with the Hosmer and Lemeshow goodness-of-fit test. The final model was used to create a simplified scoring system. RESULTS The eRRT group consisted of 474 patients who were compared to 2,575 patients in the reference group. Age and sex did not add significant discrimination to the model and were eliminated from the simplified, final model. This model, which included vital signs and diagnosis category, was found to have an AUC of 0.754 (95% confidence interval [CI] = 0.730 to 0.778) and was used to create a simplified scoring system. The odds ratio for the association of a 1-unit increase in risk score with eRRT was 1.37 (95% CI = 1.32 to 1.41; p < 0.001). When internally validated, the score was found to have an AUC of 0.759 (95% CI = 0.735 to 0.753). Calculated scores ranged from -3 to 18, which corresponded to predicted probabilities of eRRT ranging from 5.1% to 72.2%. CONCLUSIONS In summary, the PeRRT score is a simple tool that can be referenced by emergency providers at the bedside to quantify the risk of early RRT activation and potential deterioration, helping to answer the question, "How likely is my patient to trigger an RRT activation in the next twelve hours?" Given that patients who trigger eRRT have an elevated risk of morbidity and mortality, higher scores should result in resuscitative intervention, further observation in the ED, consideration of ICU admission, or direct enhanced communication between ED and inpatient providers. A prospective multicenter study is required to further validate this instrument.
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Affiliation(s)
| | - Daniel Cabrera
- Department of Emergency Medicine Mayo Clinic Rochester MN
| | - Christine M. Lohse
- Division of Biomedical Statistics and Informatics Mayo Clinic Rochester MN
| | - M. Fernanda Bellolio
- Department of Emergency Medicine Mayo Clinic Rochester MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN
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Cardona-Morrell M, Chapman A, Turner RM, Lewis E, Gallego-Luxan B, Parr M, Hillman K. Pre-existing risk factors for in-hospital death among older patients could be used to initiate end-of-life discussions rather than Rapid Response System calls: A case-control study. Resuscitation 2016; 109:76-80. [DOI: 10.1016/j.resuscitation.2016.09.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 09/18/2016] [Accepted: 09/25/2016] [Indexed: 01/26/2023]
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Timing Is Everything: Do We Need to Redesign the Afferent Limb in Rapid Response? Crit Care Med 2015; 43:2247-8. [PMID: 26376248 DOI: 10.1097/ccm.0000000000001239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Early Intervention on Long-Term Outcomes in Critically Ill Cancer: Is There a Disparity of Care? Crit Care Med 2015; 43:e466-7. [PMID: 26376269 DOI: 10.1097/ccm.0000000000001128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Story DA, Botz GH, Jones D. The Role of Rapid Response Teams in the Post-operative Care of the High-Risk Cancer Patient. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0114-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Stelfox HT, Bagshaw SM, Gao S. A retrospective cohort study of age-based differences in the care of hospitalized patients with sudden clinical deterioration. J Crit Care 2015; 30:1025-31. [PMID: 26116139 DOI: 10.1016/j.jcrc.2015.05.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 05/07/2015] [Accepted: 05/26/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE The proportion of elderly patients is increasing, but it is unknown if there are age-based differences in care of hospitalized patients with sudden clinical deterioration. We sought to examine the relation between patient age and care for hospitalized patients experiencing sudden clinical deterioration. METHODS We identified hospitalized adults (n = 5103) in 4 hospitals with sudden clinical deteriorations triggering medical emergency team (MET) activation between January 1, 2007, and December 31, 2009. We compared intensive care unit (ICU) admission rates (within 2 hours of MET activation), goals of care (resuscitative vs nonresuscitative), and hospital mortality according to age (<50, 50-64, 65-79, and 80+ years), adjusting for patient, physician, and hospital characteristics. RESULTS Age was associated with decreased likelihood of admission to ICU (P < .0001) and increased likelihood of change in goals of care (P < .0001). Compared to patients younger than 50 years, patients 80 years or older had 67% lower odds of ICU admission (odds ratio, 0.33; 95% confidence interval, 0.26-0.41) and 587% higher odds (odds ratio, 6.87; 95% confidence interval, 4.20-11.26) of having their goals of care changed to exclude resuscitation. Hospital mortality was associated with patient age, ranging from 15% to 46% (P < .0001). CONCLUSIONS Patient age is associated with care for hospitalized patients with sudden clinical deterioration, suggesting that strategies to guide care of elderly patients during MET activation may be beneficial.
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Affiliation(s)
- Henry T Stelfox
- Departments of Critical Care Medicine, Medicine, and Community Health Sciences, Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Canada.
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada.
| | - Song Gao
- Alberta Health Services, Calgary, Canada.
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Smith RJ, Santamaria JD, Faraone EE, Holmes JA, Reid DA, Tobin AE. The duration of hospitalization before review by the rapid response team: A retrospective cohort study. J Crit Care 2015; 30:692-7. [PMID: 25981444 DOI: 10.1016/j.jcrc.2015.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 04/01/2015] [Accepted: 04/04/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study is to compare cases of rapid response team (RRT) review for early deterioration (<48 hours after admission), intermediate deterioration (48 to <168 hours after admission), late deterioration (≥168 hours after admission), and cardiac arrest and to determine the association between duration of hospitalization before RRT review and mortality. METHODS This is a retrospective cohort study of RRT cases from a single hospital over 5 years (2009-2013) using administrative data and data for the first RRT attendance of each hospital episode. RESULTS Of 2843 RRT cases, 971 (34.2%) were early deterioration, 917 (32.3%) intermediate, 775 (27.3%) late, and 180 (6.3%) cardiac arrest. Compared with early deterioration patients, late deterioration patients were older (median, 71 vs 69 years; P = .005), had a higher Charlson comorbidity index (median, 2 vs 1; P < .001), more often had RRT review for respiratory distress (32.5% vs 23.5%; P < .001), more often received RRT-initiated not for resuscitation orders (8.4% vs 3.9%; P < .001), less often were discharged directly home (27.9% vs 58.4%; P < .001), and more often died in hospital (30.6% vs 12.8%; P < .001). Compared with early deterioration and adjusted for confounders, the odds ratio of death in hospital for late deterioration was 2.36 (1.81-3.08; P < .001). CONCLUSIONS Late deterioration is frequently encountered by the RRT and, compared with early deterioration, is associated with greater clinical complexity and a worse hospital outcome.
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Affiliation(s)
- Roger J Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - Espedito E Faraone
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - Jennifer A Holmes
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - David A Reid
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - Antony E Tobin
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
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Osborne S, Douglas C, Reid C, Jones L, Gardner G. The primacy of vital signs--acute care nurses' and midwives' use of physical assessment skills: a cross sectional study. Int J Nurs Stud 2015; 52:951-62. [PMID: 25704371 DOI: 10.1016/j.ijnurstu.2015.01.014] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 01/16/2015] [Accepted: 01/24/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Registered nurses and midwives play an essential role in detecting patients at risk of deterioration through ongoing assessment and action in response to changing health status. Yet, evidence suggests that clinical deterioration frequently goes unnoticed in hospitalised patients. While much attention has been paid to early warning and rapid response systems, little research has examined factors related to physical assessment skills. OBJECTIVES To determine a minimum data set of core skills used during nursing assessment of hospitalised patients and identify nurse and workplace predictors of the use of physical assessment to detect patient deterioration. DESIGN The study used a single-centre, cross-sectional survey design. SETTING AND PARTICIPANTS The study included 434 registered nurses and midwives (Grades 5-7) involved in clinical care of patients on acute care wards, including medicine, surgery, oncology, mental health and maternity service areas, at a 929-bed tertiary referral teaching hospital in Southeast Queensland, Australia. METHODS We conducted a hospital-wide survey of registered nurses and midwives using the 133-item Physical Assessment Skills Inventory and the 58-item Barriers to Registered Nurses' Use of Physical Assessment Scale. Median frequency for each physical assessment skill was calculated to determine core skills. To explore predictors of core skill utilisation, backward stepwise general linear modelling was conducted. Means and regression coefficients are reported with 95% confidence intervals. A p value <.05 was considered significant for all analyses. RESULTS Core skills used by most nurses every time they worked included assessment of temperature, oxygen saturation, blood pressure, breathing effort, skin, wound and mental status. Reliance on others and technology (F=35.77, p<.001), lack of confidence (F=5.52, p=.02), work area (F=3.79, p=.002), and clinical role (F=44.24, p<.001) were significant predictors of the extent of physical assessment skill use. CONCLUSIONS The increasing acuity of the acute care patient plausibly warrants more than vital signs assessment; however, our study confirms nurses' physical assessment core skill set is mainly comprised of vital signs. The focus on these endpoints of deterioration as dictated by early warning and rapid response systems may divert attention from and devalue comprehensive nursing assessment that could detect subtle changes in health status earlier in the patient's hospitalisation.
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Affiliation(s)
- Sonya Osborne
- Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, Queensland 4059, Australia; Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Brisbane, Queensland 4059, Australia; Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland 4029, Australia.
| | - Clint Douglas
- Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, Queensland 4059, Australia; Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Brisbane, Queensland 4059, Australia; Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland 4029, Australia
| | - Carol Reid
- Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, Queensland 4059, Australia; Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland 4029, Australia
| | - Lee Jones
- University of Queensland, Herston, Brisbane, Queensland 4059, Australia; School of Public Health, University of Queensland, Brisbane 4072, Australia
| | - Glenn Gardner
- Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, Queensland 4059, Australia; Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Brisbane, Queensland 4059, Australia; Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland 4029, Australia
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Cardona-Morrell M, Nicholson M, Hillman K. Vital Signs: From Monitoring to Prevention of Deterioration in General Wards. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2015. [DOI: 10.1007/978-3-319-13761-2_39] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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