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Winters BD. Rapid Response Systems. Crit Care Clin 2024; 40:583-598. [PMID: 38796229 DOI: 10.1016/j.ccc.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
The hospital rapid response system (RRS) is a patient safety and quality intervention that responds quickly to clinical deteriorations on general wards with the goal of preventing cardiopulmonary arrests, reducing hospital mortality, and facilitating triage and level of care escalations. The RRS is one of the first organized, and systematic, elements of the "ICU without walls" model. RRSs have been shown to be effective in preventing deterioration to cardiopulmonary arrest on general hospital wards and reducing total and unexpected hospital mortality. Recent studies have demonstrated that this benefit can be enhanced through targeted improvements and modifications of existing RRSs.
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Affiliation(s)
- Bradford D Winters
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 9127 Zayed 1800 Orealns Street, Baltimore, MD 21287, USA.
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2
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Neto R, Carvalho M, Paixão AI, Fernandes P, Castelões P. The Impact of an Intensivist-Led Critical Care Transition Program. Cureus 2022; 14:e21313. [PMID: 35186572 PMCID: PMC8848253 DOI: 10.7759/cureus.21313] [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] [Accepted: 01/16/2022] [Indexed: 11/29/2022] Open
Abstract
Objective: Evaluate the impact of a post-discharge critical care transition program (CTP) on intensive care unit (ICU) readmission, in-hospital mortality, and six-month survival. Methods: This was a prospective observational, single-center study, with a before-after design, in a critical care department in a tertiary hospital in Northern Portugal. Critically ill patients with ICU stay > 48 h or intermediate care stay >72 h or tracheostomized patients were included in the program. Historic controls included critically ill patients admitted in the six months prior to program implementation. The follow-up visit included a medical evaluation by an intensivist and a meeting with the attending physician. The primary outcome was critical care department readmission. Secondary outcomes were mortality at hospital discharge, 28-day, and six-month mortality. The readmission rate was compared between groups. Multivariate analysis and Kaplan-Meyer survival analysis were used to evaluate survival benefits. Results: Between September 2020 and March 2021, 132 patients were included in the CTP. The Control group included 196 patients. The intensivist’s assessment led to management change in 15.1% of patients. The CTP group had a non-significant lower readmission rate (0.8% vs. 4.1%; p=0.09). Multivariate analysis showed a benefit for the CTP regarding in-hospital, 28-day, and six-month mortality. Kaplan-Meyer survival analysis showed improved survival in the CTP group. Conclusions: The CTP reduced, non-significantly, the readmission rate, and significantly improved in-hospital and six-month mortality. Further analyses are needed to improve inclusion criteria and better allocate human resources.
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 839] [Impact Index Per Article: 279.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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4
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1351] [Impact Index Per Article: 450.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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Dauwe V, Poitras MÈ, Roberge V. Quels sont le fonctionnement, les caractéristiques, les effets et les modalités d’implantation des équipes d’intervention rapide ? Une revue de la littérature. Rech Soins Infirm 2021:62-75. [PMID: 33485285 DOI: 10.3917/rsi.143.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Introduction : Hospitalized patients are at risk of unrecognized clinical deterioration that may lead to adverse events.Context : Rapid Response Teams (RRTs) exist around the world as a strategy to improve patient safety.Objective : To explore how RRTs work, their characteristics, impacts, and methods of implementation.Design : Literature review.Method : Consultation of the databases CINAHL, MEDLINE, PUBMED, COCHRANE library, SCOPUS, and PROQUEST Dissertations and Theses. Keywords : “health care team” and “rapid response team”.Results : 121 articles were included. The collected data were divided into five categories : 1) composition and operation of RRTs, 2) benefits and limitations of RRTs, 3) perceptions of RRTs by health care teams, organizations, and patients, 4) implementation strategies, and 5) facilitators and barriers to implementation.Discussion : Although there are many articles related to RRTs, it appears that : 1) few studies analyze the difference in outcomes in hospitalized patients related to the composition of RRTs, 2) few studies describe how RRTs should work, 3) more studies are needed on the impacts of RRTs on hospitalized patients, 4) organizations’ and patients’ perceptions of RRTs are not well studied, and 5) more studies are needed on the best way to implement an RRT.Conclusion : The results show that there is a lack of studies on the difference in outcomes in hospitalized patients related to the composition of RRTs, on how RRTs should work, on the impacts of RRTs on hospitalized patients, on organizations’ and patients’ perceptions of RRTs, and on the factors that influence the success or failure of the implementation of an RRT.
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Tanner J, Cornish J. Routine critical care step-down programmes: Systematic review and meta-analysis. Nurs Crit Care 2020; 26:118-127. [PMID: 33159400 DOI: 10.1111/nicc.12572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients discharged from critical care to general hospital wards are vulnerable to clinical deterioration, critical care readmission, and death. In response, routine critical care stepdown programmes (CCSDPs) have been widely developed, which involve the review of all patients on general wards following discharge from critical care by multidisciplinary Outreach teams with critical care skills. AIMS AND OBJECTIVES This review aims to answer the question: do routine CCSDPs reduce readmission and/or mortality among patients discharged from critical care? DESIGN Systematic review of quantitative studies and meta-analysis. METHODS Six databases were comprehensively searched from inception (CENTRAL, Cochrane Reviews, MEDLINE, Embase, CINAHL and web of Science), alongside grey literature and trial registers. Studies investigating the effect of routine CCSDPs delivered by Outreach nurses on readmission and/or mortality following discharge from adult critical care to general hospital wards were included. Study quality was assessed using the Cochrane ROBINS-I tool. RESULTS Eight studies met the inclusion criteria, with data from 6 studies pooled in 3 meta-analyses. Among patients exposed to routine CCSDPs, pooled data estimated a statistically nonsignificant reduction in the risk of readmission to critical care (risk ratio [RR] 0.85; 95% confidence interval [CI] 0.66-1.09; P = .19), a statistically significant increase in the risk of readmission to critical care within 72 hours (RR 1.49; 95% CI 1.05-2.12; P = .03), a statistically non-significant reduction in risk of mortality following critical care discharge (RR 0.90; 95% CI 0.75-1.07; P = .22), and no association with mortality within 14 days of discharge. CONCLUSION This review is unable to definitively conclude whether routine CCSDPs reduce critical care readmission or mortality following critical care discharge. RELEVANCE TO CLINICAL PRACTICE While the synthesized evidence does not suggest a change in policy and practice are warranted, neither does it support routine CCSDPs in the absence of high-quality evidence.
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Affiliation(s)
- John Tanner
- Clinical Response Team, Guys' & St Thomas' NHS Foundation Trust, Westminster Bridge, London, UK
| | - Jocelyn Cornish
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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Österlind J, Gerhardsson J, Myrberg T. Critical care transition programs on readmission or death: A systematic review and meta-analysis. Acta Anaesthesiol Scand 2020; 64:870-883. [PMID: 32232833 DOI: 10.1111/aas.13591] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Deterioration after ICU discharge may lead to readmission or even death. Interventions (eg, critical care transition programs) have been developed to improve the clinical handover between the ICU and the ward. We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) according to Cochrane Handbook and Grading of recommendations, assessment, development and evaluations (GRADE) methodology to assess the impact of these interventions on readmission and death (PROSPERO, no CRD42019121746). METHODS We searched PubMed/MEDLINE, CINAHL, AMED, PsycINFO, and the Cochrane Central Register for Controlled Trials from inception until January 2019. We included historically controlled studies that evaluated critical care transition programs in adults discharged from the ICU. Readmission and in-hospital mortality were the primary outcomes. Risk of bias, publications bias, and the quality of evidence were assessed with the ROBINS-Itool, funnel plot and GRADE, respectively. RESULTS Fifteen observational studies were included (11 in meta-analysis). All studies had at least serious risk of bias. ICU discharge within a critical care transition program modestly reduced the risk of readmission (RR 0.78; 95% CI: 0.64-0.96; TSA-adjusted 95% CI: 0.59-1.03) but not in-hospital mortality (RR 0.82; 95% CI: 0.64-1.06; TSA-adjusted 95% CI: 0.49-1.37). There was substantial heterogeneity among studies. TSA indicated lack of firm evidence. The GRADE quality of evidence on outcomes was very low. CONCLUSIONS We found no clear benefit in terms of reducing risk of readmission or death after ICU discharge, however, with overall very low certainty of evidence.
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Affiliation(s)
- Jonas Österlind
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Sunderby Research Unit Umea University Umeå Sweden
| | - Jakob Gerhardsson
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Sunderby Research Unit Umea University Umeå Sweden
| | - Tomi Myrberg
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Sunderby Research Unit Umea University Umeå Sweden
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Coughlin DG, Kumar MA, Patel NN, Hoffman RL, Kasner SE. Preventing Early Bouncebacks to the Neurointensive Care Unit: A Retrospective Analysis and Quality Improvement Pilot. Neurocrit Care 2019; 28:175-183. [PMID: 28929392 DOI: 10.1007/s12028-017-0446-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Early unplanned readmissions of "bouncebacks" to intensive care units are a healthcare quality metric and result in higher mortality and greater cost. Few studies have examined bouncebacks to the neurointensive care unit (neuro-ICU), and we sought to design and implement a quality improvement pilot to reduce that rate. METHODS First, we performed a retrospective chart review of 504 transfers to identify potential bounceback risk factors. Risk factors were assessed on the day of transfer by the transferring physician identifying patients as "high risk" or "low risk" for bounceback. "High-risk" patients underwent an enhanced transfer process emphasizing interdisciplinary communication and rapid assessment upon transfer during a 9-month pilot. RESULTS Within the retrospective cohort, 34 of 504 (4.7%) transfers required higher levels of care within 48 h. Respiratory failure and sepsis/hypotension were the most common reasons for bounceback among this group. During the intervention, 8 of 225 (3.6%) transfers bounced back, all of who were labeled "high risk." Being "high risk" was associated with a risk of bounceback (OR not calculable, p = 0.02). Aspiration risk (OR 6.9; 95% CI 1.6-30, p = 0.010) and cardiac arrhythmia (OR 7.1; 95% CI 1.6-32, p = 0.01) were independent predictors of bounceback in multivariate analysis. Bounceback rates trended downward to 2.8% in the final phase (p for trend 0.09). Eighty-five percent of providers responded that the pilot should become standard of care. CONCLUSION Patients at high risk for bounceback after transfer from the neuro-ICU can be identified using a simple tool. Early augmented multidisciplinary communication and care for high-risk patients may improve their management in the hospital.
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Affiliation(s)
- David G Coughlin
- Department of Neurology, University of Pennsylvania, 3400 Spruce St, 3W Gates Pavilion, Philadelphia, PA, 19104, USA.
| | - Monisha A Kumar
- Department of Neurology, University of Pennsylvania, 3400 Spruce St, 3W Gates Pavilion, Philadelphia, PA, 19104, USA
| | - Neha N Patel
- Department of Internal Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Rebecca L Hoffman
- Department of Surgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, 3400 Spruce St, 3W Gates Pavilion, Philadelphia, PA, 19104, USA
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Jónasdóttir RJ, Jones C, Sigurdsson GH, Jónsdóttir H. Structured nurse-led follow-up for patients after discharge from the intensive care unit: Prospective quasi-experimental study. J Adv Nurs 2017; 74:709-723. [DOI: 10.1111/jan.13485] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2017] [Indexed: 01/20/2023]
Affiliation(s)
- Rannveig J. Jónasdóttir
- Faculty of Nursing; School of Health Sciences; University of Iceland; Reykjavik Iceland
- Intensive Care Units; Landspitali - The National University Hospital 101 Reykjavik; Iceland
| | - Christina Jones
- Institute of Ageing and Chronic Disease; Faculty of Health & Life Sciences; University of Liverpool; Liverpool UK
| | - Gisli H. Sigurdsson
- Faculty of Medicine; School of Health Sciences; University of Iceland; Vatnsmýrarvegur 16, 101 Reykjavík Iceland
- Intensive Care Units; Landspitali - The National University Hospital 101 Reykjavik; Iceland
| | - Helga Jónsdóttir
- Faculty of Nursing; School of Health Sciences; University of Iceland; Reykjavik Iceland
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Study Investigators TCMETM. Outcomes following changing from a two-tiered to a three-tiered hospital rapid response system. AUST HEALTH REV 2017; 43:178-187. [PMID: 29141770 DOI: 10.1071/ah17105] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 09/28/2017] [Indexed: 11/23/2022]
Abstract
Objectives The aim of the present study was to determine whether changing a hospital rapid response system (RRS) from a two-tiered to a three-tiered model can reduce disruption to normal hospital routines while maintaining the same overall patient outcomes. Methods Staff at an Australian teaching hospital attending medical emergency team and cardiac arrest (MET/CA) calls were interviewed after the RRS was changed from a two-tiered to three-tiered model, and the results were compared with a study using the same methods conducted before the change. The main outcome measures were changes in: (1) the incident rate resulting from staff leaving normal duties to attend MET/CA calls; (2) the cardiac arrest rate, (3) unplanned intensive care unit (ICU) admission rates; and (4) hospital mortality. Results We completed 1337 structured interviews (overall response rate 65.2%). The rate of incidents occurring as a result of staff leaving normal duties to attend MET/CA calls fell from 213.7 to 161.3 incidents per 1000 MET/CA call participant attendances (P<0.001), but the rate of cardiac arrest and unplanned ICU admissions did not change significantly. Hospital mortality was confounded by the opening of a new palliative care ward. Conclusion A three-tiered RRS may reduce disruption to normal hospital routines while maintaining the same overall patient outcomes. What is known about the topic? RRS calls result in significant disruption to normal hospital routines because staff can be called away from normal duties to attend. The best staffing model for an RRS is currently unknown. What does this paper add? The present study demonstrates, for the first time, that changing a hospital RRS from a two-tiered to a three-tiered model can reduce the rate of incidents reported by staff caused by leaving normal duties to attend RRS calls while maintaining the same overall patient outcomes. What are the implications for practitioners? Hospitals could potentially reduce disruption to normal hospital routines, without compromising patient care, by changing to a three-tiered RRS.
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Tirkkonen J, Tamminen T, Skrifvars MB. Outcome of adult patients attended by rapid response teams: A systematic review of the literature. Resuscitation 2017; 112:43-52. [PMID: 28087288 DOI: 10.1016/j.resuscitation.2016.12.023] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 12/07/2016] [Accepted: 12/24/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND An abundance of studies have investigated the impact of rapid response teams (RRTs) on in-hospital cardiac arrest rates. However, existing RRT data appear highly variable in terms of both study quality and reported uses of limitations of care, patient survival and patient long-term outcome. METHODS A systematic electronic literature search (January, 1990-March, 2016) of the PubMed and Cochrane databases was performed. Bibliographies of articles included in the full-text review were searched for additional studies. A predefined RRT cohort quality score (range 0-17) was used to evaluate studies independently by two reviewers. RESULTS Twenty-nine studies with a total of 157,383 RRT activations were included in this review. The quality of data reporting related to RRT patients was assessed as modest, with a median quality score of 8 (range 2-11). Data from the included studies indicate that a median 8.1% of RRT reviews result in limitations of medical treatment (range 2.1-25%) and 23% (8.2-56%) result in a transfer to intensive care. A median of 29% (6.9-35%) of patients transferred to intensive care died during that admission. The median hospital mortality of patients reviewed by RRT is 26% (12-60%), and the median 30-day mortality rate is 29% (8-39%). Data on long-term survival is minimal. No data on functional outcomes was identified. CONCLUSIONS Patients reviewed by rapid response teams have a high and variable mortality rate, and limitations of care are commonly used. Data on the long-term outcomes of RRT are lacking and needed.
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Affiliation(s)
- Joonas Tirkkonen
- Department of Intensive Care Medicine, Tampere University Hospital and Department of Anaesthesiology and Intensive Care Medicine, Seinäjoki Central Hospital, P.O. Box 2000, FI-33521 Tampere, Finland.
| | - Tero Tamminen
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University and Helsinki University Hospital, Finland
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University and Helsinki University Hospital, Finland; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Australia
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12
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Subramaniam A, Botha J, Tiruvoipati R. The limitations in implementing and operating a rapid response system. Intern Med J 2016; 46:1139-1145. [PMID: 26913367 DOI: 10.1111/imj.13042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 02/05/2023]
Abstract
Despite the widespread introduction of rapid response systems (RRS)/medical emergency teams (MET), there is still controversy regarding how effective they are. While there are some observational studies showing improved outcomes with RRS, there are no data from randomised controlled trials to support the effectiveness. Nevertheless, the MET system has become a standard of care in many healthcare organisations. In this review, we present an overview of the limitations in implementing and operating a RRS in modern healthcare.
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Affiliation(s)
- A Subramaniam
- Department of Intensive Care, Frankston Hospital, Monash University, Melbourne, Victoria, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria, Australia.
- Department of Intensive Care, Monash University, Melbourne, Victoria, Australia.
| | - J Botha
- Department of Intensive Care, Frankston Hospital, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Monash University, Melbourne, Victoria, Australia
| | - R Tiruvoipati
- Department of Intensive Care, Frankston Hospital, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Monash University, Melbourne, Victoria, Australia
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Abstract
Although anesthesia-associated mortality has been significantly reduced down to 0.00068-0.00082% over the last decades, recent studies have revealed a high perioperative mortality of 0.8- 4%. Apart from anesthesia and surgery-induced major complications, perioperative mortality is primarily negatively influenced by individual patient comorbidities. These risk factors predispose for acute critical incidents (e.g., myocardial infarction); however, the majority of fatal complications are a result of slowly progressing conditions, particularly infections or the sequelae of systemic inflammation. This implicates a broad window of opportunity for the detection and treatment of slow-onset complications to improve the perioperative outcome. The term "failure to rescue" (FTR), i.e., the proportion of patients who die from major complications compared to the number of all patients with complications, has been introduced as a valid indicator for the quality of perioperative care. Growing evidence has already shown that FTR is an underestimated factor in perioperative medicine accounting for or at least being involved in the development of postoperative mortality. While the incidence of severe postoperative complications amazingly does not show much variation between hospitals, FTR shows significant differences implying a major potential for improvement. With 14 million surgical procedures per year in Germany, a postoperative mortality of approximately 1% and an avoidable FTR rate of 40% mean that there are an estimated 60,000 preventable deaths per year. Hence, in the future it will be imperative to (1) identify patients at risk, (2) to prevent the development of postoperative complications with the use of adequate adjunctive therapeutic strategies, (3) to establish surveillance and monitoring systems for the early detection of postoperative complications and (4) to treat postoperative complications efficiently and in time when they arise.
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Affiliation(s)
- O Boehm
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland
| | - M K A Pfeiffer
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland
| | - G Baumgarten
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland
| | - A Hoeft
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland.
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Alberto L, Gillespie BM, Green A, Martínez MDC, Cañete A, Zotarez H, Díaz CA, Enriquez M, Gerónimo M, Chaboyer W. Activities undertaken by Intensive Care Unit Liaison Nurses in Argentina. Aust Crit Care 2016; 30:74-78. [PMID: 27451146 DOI: 10.1016/j.aucc.2016.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 06/22/2016] [Accepted: 06/25/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The Intensive Care Unit Liaison Nurse (ICULN), also known as an outreach nurse, is an advanced practice nursing role that emerged in the late 1990s in Australia and the United Kingdom (UK). Little is known about this role in less developed economies. OBJECTIVE To describe the activities undertaken by ICULNs in Argentina. METHODS Prospective, descriptive, observational, single site study in an Argentinean metropolitan tertiary referral hospital. Adult patients under ICULN follow up were included in the sample. Data on ICULN activities and patients were collected using an established tool developed by The Australian Intensive Care Unit Liaison Nurse Forum. Descriptive statistics were used to summarise the findings. RESULTS Two hundred patients were visited by the ICULNs during the study period. The mean age of patients was 52.5 years (SD 17.7). Cardiovascular disease (n=104, 52%), respiratory disease (n=90, 45%) and diabetes (n=40, 20%) were the most common comorbidities. 110 (55%) patients had surgical procedures. The primary reasons for ICULN visit were follow up post ICU discharge (n=138, 69%) and ward referral (n=46, 23%). 136 (68%) patients received up to 3 visits; the remaining 64 (32%) patients received ≥4 visits. In those patients in need of ≥4 visits ICULNs initiated more non-medical treatments (100%), referred to escalate treatment (35%) and to a higher level of care (13.8%) than in those who were visited up to 3 times. CONCLUSIONS This study is the first to document ICULN activity in Argentina using an international framework and data set. These findings can assist with understanding an advanced practice nursing role in Argentina. It may facilitate future comparisons with other contexts and could help managers implementing the role in similar settings. Further investigation will help develop this practice and document its influence on patient outcomes.
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Affiliation(s)
- Laura Alberto
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina; Menzies Health Institute Qld (MHIQ), Griffith University, Queensland, Australia; School of Nursing & Midwifery, Griffith University, Queensland, Australia.
| | - Brigid M Gillespie
- Menzies Health Institute Qld (MHIQ), Griffith University, Queensland, Australia; NHMRC Centre for Research Excellence in Nursing, Griffith University, Queensland, Australia
| | - Anna Green
- ICU Liaison Nurse Service, Western Health (1998 - 2015), Victoria, Australia
| | - Maria Del Carmen Martínez
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina; School of Nursing, Universidad de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Angel Cañete
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina
| | - Haydee Zotarez
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina
| | - Carlos Alberto Díaz
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina; Economy and Health Management Specialization Program, Universidad ISALUD, Ciudad de Buenos Aires, Argentina
| | - Marcelino Enriquez
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina
| | - Mario Gerónimo
- Sanatorio de Alta Complejidad Sagrado Corazón, Ciudad de Buenos Aires, Argentina
| | - Wendy Chaboyer
- Menzies Health Institute Qld (MHIQ), Griffith University, Queensland, Australia; NHMRC Centre for Research Excellence in Nursing, Griffith University, Queensland, Australia
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Jónasdóttir RJ, Klinke ME, Jónsdóttir H. Integrative review of nurse-led follow-up after discharge from the ICU. J Clin Nurs 2015; 25:20-37. [DOI: 10.1111/jocn.12939] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Rannveig J. Jónasdóttir
- Faculty of Nursing; University of Iceland; Reykjavik Iceland
- Intensive Care Unit; Landspítali The National University Hospital of Iceland; Reykjavik Iceland
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Kareliusson F, De Geer L, Tibblin AO. Risk prediction of ICU readmission in a mixed surgical and medical population. J Intensive Care 2015; 3:30. [PMID: 26157581 PMCID: PMC4495798 DOI: 10.1186/s40560-015-0096-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 06/12/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Readmission to intensive care units (ICU) is accompanied with longer ICU stay as well as higher ICU, in-hospital and 30-day mortality. Different scoring systems have been used in order to predict and reduce readmission rates. METHODS The purpose of this study was to evaluate the Stability and Workload Index for Transfer (SWIFT) score as a predictor of readmission. Further, we wanted to study steps and measures taken at the ward prior to readmission. RESULTS This was a retrospective study conducted at the mixed surgical and medical ICU at Linköping University Hospital. One thousand sixty-seven patients >18 years were admitted to the ICU during 2 years and were included in the study. During the study period, 27 patients were readmitted to the ICU. Readmitted patients had a higher SWIFT score than the non-readmitted (16.1 ± 6.8 vs. 13.0 ± 7.5, p = 0.03) at discharge. The total ICU length of stay was longer (7.5 ± 7.5 vs. 2.9 ± 5.1, p = 0.004), and the 30-day mortality was higher (26 vs. 7 %, p < 0.001) for readmitted patients. Fifty-six percent of readmitted patients were assessed by the critical care outreach service (CCOS) at the ward prior to ICU readmission. A SWIFT score of 15 or more was associated with a significantly higher readmission rate (p = 0.03) as well as 30-day mortality (p < 0.001) compared to a score of ≤14. CONCLUSIONS A SWIFT score of 15 or more is associated with higher readmission rate and 30-day mortality. The SWIFT score could therefore be used for risk prediction for readmission and mortality at ICU discharge.
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Affiliation(s)
- Frida Kareliusson
- Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden ; Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Lina De Geer
- Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden ; Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Anna Oscarsson Tibblin
- Department of Anaesthesiology and Intensive Care, Linköping University, Linköping, Sweden ; Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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van Sluisveld N, Hesselink G, van der Hoeven JG, Westert G, Wollersheim H, Zegers M. Improving clinical handover between intensive care unit and general ward professionals at intensive care unit discharge. Intensive Care Med 2015; 41:589-604. [PMID: 25672275 PMCID: PMC4392116 DOI: 10.1007/s00134-015-3666-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 01/14/2015] [Indexed: 11/26/2022]
Abstract
Purpose To systematically review and evaluate the effectiveness of interventions in order to improve the safety and efficiency of patient handover between intensive care unit (ICU) and general ward healthcare professionals at ICU discharge. Methods PubMed, CINAHL, PsycINFO, EMBASE, Web of Science, and the Cochrane Library were searched for intervention studies with the aim to improve clinical handover between ICU and general ward healthcare professionals that had been published up to and including June 2013. The methods for article inclusion and data analysis were pre-specified and aligned with recommendations outlined in the PRISMA guideline. Two reviewers independently extracted data (study purpose, setting, population, method of sampling, sample size, intervention characteristics, outcome, and implementation activities) and assessed the quality of the included studies. Results From the 6,591 citations initially extracted from the six databases, we included 11 studies in this review. Of these, six (55 %) reported statistically significant effects. Effective interventions included liaison nurses to improve communication and coordination of care and forms to facilitate timely, complete and accurate handover information. Effective interventions resulted in improved continuity of care (e.g., reduced discharge delay) and in reduced adverse events. Inconsistent effects were observed for use of care, namely, reduction of length of stay versus increase of readmissions to higher care. No statistically significant effects were found in the reduction of mortality. The overall methodological quality of the 11 studies reviewed was relatively low, with an average score of 4.5 out of 11 points. Conclusions This review shows that liaison nurses and handover forms are promising interventions to improve the quality of patient handover between the ICU and general ward. More robust evidence is needed on the effectiveness of interventions aiming to improve ICU handover and supportive implementation strategies. Electronic supplementary material The online version of this article (doi:10.1007/s00134-015-3666-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nelleke van Sluisveld
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, 9101, 6500 HB, Nijmegen, The Netherlands,
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19
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Incidents resulting from staff leaving normal duties to attend medical emergency team calls. Med J Aust 2014; 201:528-31. [DOI: 10.5694/mja14.00647] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 09/11/2014] [Indexed: 11/17/2022]
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20
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Evaluation of the feasibility and acceptability of a nursing intervention program to facilitate the transition of adult SCI patients and their family from ICU to a trauma unit. Int J Orthop Trauma Nurs 2014. [DOI: 10.1016/j.ijotn.2013.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta-analysis. Crit Care Med 2014; 42:179-87. [PMID: 23989177 DOI: 10.1097/ccm.0b013e3182a272c0] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether critical care transition programs reduce the risk of ICU readmission or death, when compared with standard care among adults who survived their incident ICU admission. DATA SOURCES MEDLINE, EMBASE, CENTRAL, CINAHL, and two clinical trial registries were searched from inception to October 2012. STUDY SELECTION Studies that examined the effects of critical care transition programs on the risk of ICU readmission or death among patients discharged from ICU were selected for review. A critical care transition program included any rapid response team, medical emergency team, critical care outreach team, or ICU nurse liaison program that provided follow-up for patients discharged from ICU. DATA EXTRACTION Two reviewers independently extracted data on study characteristics, transition program characteristics, and outcomes (number of ICU readmissions and in-hospital deaths following discharge from ICU). DATA SYNTHESIS From 3,120 citations, nine before-and-after studies were included. The studies examined medical-surgical populations and described transition programs that were a component of a hospital's outreach team (n = 6) or nurse liaison program (n = 3). Meta-analysis using a fixed-effect model demonstrated a reduced risk of ICU readmission (risk ratio, 0.87 [95% CI, 0.76-0.99]; p = 0.03; I2 = 0%) but no significant reduction in hospital mortality (risk ratio, 0.84 [95% CI, 0.66-1.05]; p = 0.1; I2 = 16%) associated with a critical care transition program. The risk of ICU readmission was similar whether the transition program was included within an outreach team or a nurse liaison program and did not depend on the presence of an intensivist. CONCLUSIONS Critical care transition programs appear to reduce the risk of ICU readmission in patients discharged from ICU to a general hospital ward. Given methodological limitations of the included before-and-after studies, additional research should confirm these observations and explore the ideal model for these programs before recommending implementation.
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Ramsay P, Huby G, Thompson A, Walsh T. Intensive care survivors' experiences of ward-based care: Meleis' theory of nursing transitions and role development among critical care outreach services. J Clin Nurs 2013; 23:605-15. [PMID: 24354952 DOI: 10.1111/jocn.12452] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2013] [Indexed: 11/26/2022]
Abstract
AIMS AND OBJECTIVES To explore the psychosocial needs of patients discharged from intensive care, the extent to which they are captured using existing theory on transitions in care and the potential role development of critical care outreach, follow-up and liaison services. BACKGROUND Intensive care patients are at an increased risk of adverse events, deterioration or death following ward transfer. Nurse-led critical care outreach, follow-up or liaison services have been adopted internationally to prevent these potentially avoidable sequelae. The need to provide patients with psychosocial support during the transition to ward-based care has also been identified, but the evidence base for role development is currently limited. DESIGN AND METHODS Twenty participants were invited to discuss their experiences of ward-based care as part of a broader study on recovery following prolonged critical illness. Psychosocial distress was a prominent feature of their accounts, prompting secondary data analysis using Meleis et al.'s mid-range theory on experiencing transitions. RESULTS Participants described a sense of disconnection in relation to profound debilitation and dependency and were often distressed by a perceived lack of understanding, indifference or insensitivity among ward staff to their basic care needs. Negotiating the transition between dependence and independence was identified as a significant source of distress following ward transfer. Participants varied in the extent to which they were able to express their needs and negotiate recovery within professionally mediated boundaries. CONCLUSION These data provide new insights into the putative origins of the psychosocial distress that patients experience following ward transfer. RELEVANCE TO CLINICAL PRACTICE Meleis et al.'s work has resonance in terms of explicating intensive care patients' experiences of psychosocial distress throughout the transition to general ward-based care, such that the future role development of critical care outreach, follow-up and liaison services may be more theoretically informed.
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Affiliation(s)
- Pam Ramsay
- University of Edinburgh/NHS Lothian, Edinburgh, UK
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23
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McNeill G, Bryden D. Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review. Resuscitation 2013; 84:1652-67. [DOI: 10.1016/j.resuscitation.2013.08.006] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 07/22/2013] [Accepted: 08/03/2013] [Indexed: 12/15/2022]
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Trinh VQ, Trinh QD, Tian Z, Hu JC, Shariat SF, Perrotte P, Karakiewicz PI, Sun M. In-hospital mortality and failure-to-rescue rates after radical cystectomy. BJU Int 2013; 112:E20-7. [PMID: 23795794 DOI: 10.1111/bju.12214] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To show the underlying variability in peri-operative mortality after radical cystectomy (RC) by analysing failure-to-rescue (FTR) rates, i.e. deaths after complications. MATERIALS AND METHODS Patients undergoing RC for non-metastatic bladder cancer (BCa) were identified from the Nationwide Inpatient Sample, 1999-2009, resulting in a weighted estimate of 79,972 patients. The FTR rates were assessed according to patient and hospital characteristics, as well as complication type. Generalized linear regression analyses were performed. RESULTS Overall, 26,740 patients had a complication, corresponding to a FTR rate of 5.5%. Septicaemia (odds ratio [OR]: 13.41, P < 0.001) and cardiac (OR: 3.97, P < 0.001), wound-related (OR: 2.12, P < 0.001), genitourinary (OR: 1.62, P = 0.045) and haematological (OR: 1.78, P = 0.008) complications were associated with FTR. Older age (OR: 1.05, P < 0.001), increasing comorbidities (OR: 1.33, P < 0.001), Medicare (OR: 1.52, P = 0.016), and Medicaid insurance status (OR: 2.10, P = 0.029) were associated with higher odds of FTR. Conversely, increasing hospital volume (OR: 0.992, P = 0.014) reduced the odds of FTR. CONCLUSIONS Whereas both patient and hospital characteristics were associated with increased odds of FTR, the occurrence of septicaemia and cardiac complications were the most strongly associated with a higher risk of in-hospital mortality.
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Affiliation(s)
- Vincent Q Trinh
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI 48202, USA.
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25
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Leach LS, Mayo AM. Rapid response teams: qualitative analysis of their effectiveness. Am J Crit Care 2013; 22:198-210. [PMID: 23635929 DOI: 10.4037/ajcc2013990] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Multidisciplinary rapid response teams focus on patients' emergent needs and manage critical situations to prevent avoidable deaths. Although research has focused primarily on outcomes, studies of the actual team effectiveness within the teams from multiple perspectives have been limited. OBJECTIVE To describe effectiveness of rapid response teams in a large teaching hospital in California that had been using such teams for 5 years. METHODS The grounded-theory method was used to discover if substantive theory might emerge from interview and/or observational data. Purposeful sampling was used to conduct in-person semistructured interviews with 17 key informants. Convenience sampling was used for the 9 observed events that involved a rapid response team. Analysis involved use of a concept or indicator model to generate empirical results from the data. Data were coded, compared, and contrasted, and, when appropriate, relationships between concepts were formed. Results Dimensions of effective team performance included the concepts of organizational culture, team structure, expertise, communication, and teamwork. CONCLUSIONS Professionals involved reported that rapid response teams functioned well in managing patients at risk or in crisis; however, unique challenges were identified. Teams were loosely coupled because of the inconsistency of team members from day to day. Team members had little opportunity to develop relationships or team skills. The need for team training may be greater than that among teams that work together regularly under less time pressure to perform. Communication between team members and managing a crisis were critical aspects of an effective response team.
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Affiliation(s)
- Linda Searle Leach
- Linda Searle Leach is an assistant professor, School of Nursing, University of California Los Angeles, Los Angeles, California. Ann M. Mayo is a professor, Hahn School of Nursing and Health Science, University of San Diego, San Diego, California
| | - Ann M. Mayo
- Linda Searle Leach is an assistant professor, School of Nursing, University of California Los Angeles, Los Angeles, California. Ann M. Mayo is a professor, Hahn School of Nursing and Health Science, University of San Diego, San Diego, California
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Bernard AM, Czaja AS. Unplanned pediatric intensive care unit readmissions: a single-center experience. J Crit Care 2013; 28:625-33. [PMID: 23602033 DOI: 10.1016/j.jcrc.2013.02.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 02/04/2013] [Accepted: 02/10/2013] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of the study was to compare patients readmitted to the pediatric intensive care unit (PICU) unexpectedly within 48 hours (early), more than 48 hours from transfer (late), or not readmitted during the same hospitalization. MATERIALS AND METHODS A retrospective study (2007-2009) was performed at a tertiary care pediatric academic hospital. Readmitted at-risk patients were grouped by timing of readmission, and a sample of nonreadmitted patients was randomly selected. Early readmissions were compared to late readmissions and to nonreadmissions. RESULTS Of 3805 eligible patients, 3.9% had an unplanned PICU readmission with almost half occurring within 48 hours. Median times to readmission were 21.5 hours (early) and 7 days (late). Compared with late readmissions, early readmissions were more often admitted from and transferred to a surgical service, transferred on a weekend, and readmitted with the same primary diagnosis. Compared with nonreadmitted patients, independent risk factors for early readmission were admission source and respiratory support at PICU transfer. Readmitted patients had longer total PICU and hospital lengths of stay than nonreadmitted patients. Late readmissions had a higher mortality than early readmissions. CONCLUSIONS Patients requiring an unplanned PICU readmission had worse outcomes than those without a readmission. Future studies should focus on identifying modifiable risk factors for targeted interventions.
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Affiliation(s)
- Aline M Bernard
- Division of Critical Care, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, Aurora, CO, USA
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Butcher BW, Vittinghoff E, Maselli J, Auerbach AD. Impact of proactive rounding by a rapid response team on patient outcomes at an academic medical center. J Hosp Med 2013; 8:7-12. [PMID: 23024019 PMCID: PMC3538927 DOI: 10.1002/jhm.1977] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 06/26/2012] [Accepted: 07/30/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND The impact of rapid response teams (RRT) on patient outcomes remains uncertain. OBJECTIVE To examine the effect of proactive rounding by an RRT on outcomes of hospitalized adults discharged from intensive care. DESIGN Retrospective, observational study. SETTING Academic medical center. PATIENTS All adult patients discharged alive from the intensive care unit (ICU) at the University of California San Francisco Medical Center between January 2006 and June 2009. INTERVENTION Introduction of proactive rounding by an RRT. MEASUREMENTS Outcomes included the ICU readmission rate, ICU average length of stay (LOS), and in-hospital mortality of patients discharged from the ICU. Data were obtained from administrative billing databases and analyzed using an interrupted time series (ITS) model. RESULTS We analyzed 17 months of preintervention data and 25 months of postintervention data. Introduction of proactive rounding by the RRT did not change the ICU readmission rate (6.7% before vs 7.3% after; P = 0.24), the ICU LOS (5.1 days vs 4.9 days; P = 0.24), or the in-hospital mortality of patients discharged from the ICU (6.0% vs 5.5%; P = 0.24). ITS models testing the impact of proactive rounding on secular trends found no improvement in any of the 3 clinical outcomes relative to their preintervention trends. CONCLUSIONS Proactive rounding by an RRT did not improve patient outcomes, raising further questions about RRT benefits.
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Affiliation(s)
- Brad W Butcher
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA.
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Impact of a new model of intensive care medicine upon healthcare in a department of intensive care medicine. Med Intensiva 2012; 37:27-32. [PMID: 22959859 DOI: 10.1016/j.medin.2012.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 06/07/2012] [Accepted: 06/08/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate a new organizational model in an intensive care unit, with the implementation of early warning systems and a support unit. DESIGN A retrospective, comparative cohort study was carried out. SETTING The study was carried out in the Department of Intensive Care Medicine (DICM) of a tertiary hospital (2009-2011), with the comparison of three time periods (P1, P2 and P3) that differed in terms of organization and logistics. PATIENTS We analyzed all patients admitted to the ICU during the study period. Patients from maternal and infant intensive care were excluded. VARIABLES OF INTEREST Percentage of patients with stays of under two days, with invasiveness used; readmission to the DICM, type of admission and percentage of stays of longer than one month; APACHE II score, mean stay in the ICU and shift distribution of the admissions. RESULTS We analyzed a sample of 3209 patients (65% males), with a mean age of 58.23 (18.23) years, a mean APACHE II score of 16.67 (8.23), and presenting an occupancy rate of 7.3 (10.3) days in the analyzed period. The ratio APACHE II score/number of beds was 0.69 (0.34) in P1, compared to 0.68 (0.33) in P2 and 0.76 (0.37) in P3 (p<0.001). The intervention surveillance grade (grade 1) was 42% (39-46%) in P1, 40% (37-43%) in P2 and 31% (28-35%) in P3 (p<0.001). The average stay in the ICU ranged from 7.10 days (8.82) in P1 to 6.60 days (9.49) in P2 and 8.42 days (12.73) in P3 (p<0.001). CONCLUSIONS There has been an increase in the number of patients seen in our DICM, with a decrease in the patients admitted to the conventional ICU. Patients now admitted to the ICU are more seriously ill, require a greater level of intervention, and give rise to an increase in the mean duration of stay in the ICU.
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Cheung W, Gullick J, Thanakrishnan G, Snars J, Milliss D, Tan J. Expansion of a medical emergency team system to a mental health facility. Resuscitation 2012; 83:293-6. [DOI: 10.1016/j.resuscitation.2011.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 07/19/2011] [Accepted: 08/12/2011] [Indexed: 11/26/2022]
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Chiang VC. Surviving a critical illness through mutually being there with each other: A grounded theory study. Intensive Crit Care Nurs 2011; 27:317-30. [DOI: 10.1016/j.iccn.2011.09.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Revised: 08/31/2011] [Accepted: 09/19/2011] [Indexed: 11/15/2022]
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Pattison N, Eastham E. Critical care outreach referrals: a mixed-method investigative study of outcomes and experiences. Nurs Crit Care 2011; 17:71-82. [PMID: 22335348 DOI: 10.1111/j.1478-5153.2011.00464.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To explore referrals to a critical care outreach team (CCOT), associated factors around patient management and survival to discharge, and the qualitative exploration of referral characteristics (identifying any areas for service improvement around CCOT). METHOD A single-centre mixed method study in a specialist hospital was undertaken, using an explanatory design: participant selection model. In this model, quantitative results (prospective and retrospective episode of care review, including modified early warning system (MEWS), time and delay of referral and patient outcomes for admission and survival) are further explained by qualitative (interview) data with doctors and nurses referring to outreach. Quantitative data were analysed using SPSS +17 and 19, and qualitative data were analysed using grounded theory principles. RESULTS A large proportion of referrals (124/407 = 30·5%) were made by medical staff. For 97 (97/407 = 23·8%) referrals, there was a delay between the point at which patients deteriorated (as verified by retrospective record review and MEWS score triggers) and the time at when patients were referred. The average delay was 2·96 h (95% CI 1·97-3·95; SD 9·56). Timely referrals were associated with improved outcomes; however, no causal attribution can be made from the circumstances around CCOT referral. Qualitative themes included indications for referral, facilitating factors for referral, barriers to referral and consequences of referral, with an overarching core theory of reassurance. Outreach was seen as back-up and this core theory demonstrates the important, and somewhat less tangible, role outreach has in supporting ward staff to care for at-risk patients. CONCLUSION Mapping outreach episodes of care and patient outcomes can help highlight areas for improvement. This study outlines reasons for referral and how outreach can facilitate patient pathways in critical illness.
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Affiliation(s)
- Natalie Pattison
- N Pattison, Clinical Nursing Research Fellow, CCU Outreach Office, The Royal Marsden NHS Foundation Trust, Sutton, Surrey SM2 5PT, UK.
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Laurens NH, Dwyer TA. The effect of medical emergency teams on patient outcome: a review of the literature. Int J Nurs Pract 2011; 16:533-44. [PMID: 21129105 DOI: 10.1111/j.1440-172x.2010.01879.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This paper presents a review of literature on the impact of the medical emergency team (MET) on inpatient mortality, cardiopulmonary arrests or unscheduled intensive care unit (ICU) admissions. A total of 14,172 abstracts and 98 full text papers were reviewed. In total, 24 met the inclusion criteria, 2 used a cluster-randomized controlled trial, 11 before and after, 6 retrospective analyses, 4 prospective cohorts and 1 not reported. There is moderate to strong evidence that METs are associated with decreased mortality and cardiac arrest rates, and weak evidence on its impact on ICU admission rate reductions. This evidence suffers from the flaws with only two randomized controlled trials examining differing outcome measures with differing results. Poor methodology and failure to report both quality improvement co-interventions and time response rates of METs, limit the strength of the evidence that METs are effective interventions for preventing mortality, code rates or unscheduled ICU admissions. Studies with improved implementation practices and evaluation of the efficacy of MET is warranted.
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Cioffi J, Conway R, Everist L, Scott J, Senior J. ‘Changes of concern’ for detecting potential early clinical deterioration: A validation study. Aust Crit Care 2010; 23:188-96. [DOI: 10.1016/j.aucc.2010.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 03/16/2010] [Accepted: 04/30/2010] [Indexed: 11/15/2022] Open
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Thirty-day mortality in critical care outreach patients with cancer: an investigative study of predictive factors related to outreach referral episodes. Resuscitation 2010; 81:1670-5. [PMID: 20708327 DOI: 10.1016/j.resuscitation.2010.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Revised: 07/13/2010] [Accepted: 07/13/2010] [Indexed: 11/23/2022]
Abstract
AIM To establish factors that predict outcome in critically ill, deteriorating cancer patients through critical care outreach referral episodes, characteristics and care reviews. METHODS A population-based prospective and retrospective study was undertaken with analysis exploring predictive factors regarding critically ill cancer patients referred to a critical care outreach team. Data collected included: diagnosis; presenting problem; early warning scores at referral and at deterioration; physiological and observation data; admission to critical care, length of stay; 30-day mortality; limitation of care including precipitating DNAR orders and documentation of not for CCU admission/intervention). RESULTS Data were collected on 407 episodes from 318 patients over a period of 8 months from 2006 to 2007. Outreach initiated decisions to limit care with medical teams in 32.2% (n=103/318) of all patients. Early warning scores were not predictive of outcome. A high heart rate at referral (HR), a high potassium, low SpO2 at time of deterioration were independently predictive of 30-day mortality. The logistic regression (LR) model, using these three variables correctly predicts the 30-day outcome of 71% of the patients, demonstrating a relatively high predictability in this patient population. The odds of mortality increase with a higher potassium, heart rate and as the oxygen saturation at deterioration (DSpO(2)) worsen. Management factors included limitation of care, which is highly associated with 30-day mortality. Cancer patients recently receiving chemotherapy may have an increased mortality once admitted to critical care. Being a haemato-oncology patient, or the timeliness of critical care outreach referral does not appear to affect 30-day mortality. CONCLUSION The LR model was able to predict 30-day outcome of 71% of the patients, demonstrating a reasonably high predictability in this cancer patient population. Critical care outreach initiated discussions on limiting treatment which had an effect on mortality.
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Endacott R, Chaboyer W, Edington J, Thalib L. Impact of an ICU Liaison Nurse Service on major adverse events in patients recently discharged from ICU. Resuscitation 2010; 81:198-201. [DOI: 10.1016/j.resuscitation.2009.10.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 10/08/2009] [Accepted: 10/08/2009] [Indexed: 11/30/2022]
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Immediate and long-term impact of medical emergency teams on cardiac arrest prevalence and mortality: A plea for periodic basic life-support training programs*. Crit Care Med 2009; 37:3054-61. [DOI: 10.1097/ccm.0b013e3181b02183] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Endacott R, Eliott S, Chaboyer W. An integrative review and meta-synthesis of the scope and impact of intensive care liaison and outreach services. J Clin Nurs 2009; 18:3225-36. [DOI: 10.1111/j.1365-2702.2009.02914.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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A systems approach to the early recognition and rapid administration of best practice therapy in sepsis and septic shock. Curr Opin Crit Care 2009; 15:301-7. [PMID: 19561493 DOI: 10.1097/mcc.0b013e32832e3825] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW The early recognition and treatment of sepsis is paramount to reducing the mortality of this disease. However, unlike trauma, stroke or acute myocardial infarction, the initial signs of sepsis are subtle and easily missed by clinicians. Thus, hospital-based systems are needed to identify and triage patients who might be septic. This review focuses on the early diagnosis of sepsis and the implementation of a systems-based approach to help coordinate the identification and treatment of patients with this disease. RECENT FINDINGS Alterations in traditional hemodynamic parameters, such as blood pressure and heart rate, are poor predictors of the presence of septic shock. Other more subtle findings (such as the 10 signs of vitality) are stronger determinants of poor tissue perfusion in a patient who may be septic. Early detection of a patient who is 'in trouble' on the ward by bedside nurses or physicians and activation of a medical emergency team has been shown to improve outcome. By coupling the medical emergency team with early goal-directed therapy, patients with sepsis can be discovered earlier and have therapy instituted within the so-called 'golden hour', first appreciated with trauma care. SUMMARY The institution of a rapid response system for the detection and treatment of septic shock requires a multidisciplinary approach. The infrastructure to create such a system must be facilitated by administrators and implemented by front-line healthcare providers. Continuous assessment of the outcome benefit of such a system by a quality assurance team is the final part of a truly integrated approach to sepsis treatment.
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Cheung W, Gullick J, Thanakrishnan G, Jacobs R, Au W, Uy J, Fick M, Narayan P, Ralston S, Tan J. Injuries occurring in hospital staff attending medical emergency team (MET) calls--a prospective, observational study. Resuscitation 2009; 80:1351-6. [PMID: 19837501 DOI: 10.1016/j.resuscitation.2009.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 08/18/2009] [Accepted: 09/09/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Clinical emergency response systems such as medical emergency teams (MET) have been implemented in many hospitals worldwide, but the effect that these systems have on injuries to hospital staff is unknown. The objective of this study was to determine the rate and nature of injuries occurring in hospital staff attending MET calls. METHODS This study was a prospective, observational study, using a structured interview, of 1265 MET call participants, in a 650 bed urban, teaching hospital. Data was collected on the number and the nature of injuries occurring in hospital staff attending MET calls. RESULTS Over 131 days, 248 MET calls were made. An average of 8.1 staff participated in each MET call. The overall injury rate was 13 (95% confidence interval (CI) 7-20) per 1000 MET participant attendances, and 70 (95% CI 38-102) per 1000 MET calls. One injured participant required time off-work, an injury requiring time off-work rate of 1 (95% CI 0-4) per 1000 MET participant attendances, or 4 (95% CI 0-27) per 1000 MET calls. The relative risk of sustaining an injury if the MET participant performed chest compressions, contacted patient body fluids on clothing or protective equipment, without direct contact to skin or mucosa, or lifted the patient or a patient body part was 11.0 (95% CI 4.2-28.6), 8.7 (95% CI 3.4-22.0) and 5.5 (95% CI 2.1-14.2), respectively. CONCLUSION The rate of injuries occurring to hospital staff attending MET calls is relatively low, and many injuries could be considered relatively minor.
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Affiliation(s)
- Winston Cheung
- Department of Intensive Care, Concord Repatriation General Hospital, Concord, Sydney, NSW, Australia.
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The role and effectiveness of a nurse practitioner led critical care outreach service. Intensive Crit Care Nurs 2008; 24:375-82. [DOI: 10.1016/j.iccn.2008.04.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Revised: 04/07/2008] [Accepted: 04/16/2008] [Indexed: 11/18/2022]
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Abstract
The present chapter considers the evolving role of critical care outreach in the general hospital setting and applied to obstetric patients, the mechanics of transferring critically ill obstetric patients to critical care and radiology areas, the scoring systems in use in critical care, and the difficulties in applying these scoring systems to obstetric patients.
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Affiliation(s)
- N A Barrett
- Guy's and St Thomas' Hospitals, Lambeth Palace Road, London SE1 7EH, UK.
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Hravnak M, Edwards L, Clontz A, Valenta C, Devita MA, Pinsky MR. Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system. ACTA ACUST UNITED AC 2008; 168:1300-8. [PMID: 18574087 DOI: 10.1001/archinte.168.12.1300] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND To our knowledge, detection of cardiorespiratory instability using noninvasive monitoring via electronic integrated monitoring systems (IMSs) in intermediate or step-down units (SDUs) has not been described. We undertook this study to characterize respiratory status in an SDU population, to define features of cardiorespiratory instability, and to evaluate an IMS index value that should trigger medical emergency team (MET) activation. METHODS This descriptive, prospective, single-blinded, observational study evaluated all patients in a 24-bed SDU in a university medical center during 8 weeks from November 16, 2006, to January 11, 2007. An IMS (BioSign; OBS Medical, Carmel, Indiana) was inserted into the standard noninvasive hardwired monitoring system and used heart rate, blood pressure, respiratory rate, and peripheral oxygen saturation by pulse oximetry to develop a single neural networked signal, or BioSign Index (BSI). Data were analyzed for cardiorespiratory instability according to BSI trigger value and local MET activation criteria. Staff were blinded to BSI data collected in 326 patients (total census). RESULTS Data for 18 248 hours of continuous monitoring were captured. Data for peripheral oxygen saturation by pulse oximetry were absent in 30% of monitored hours despite being a standard of care. Cardiorespiratory status in most patients (243 of 326 [74.5%]) was stable throughout their SDU stay, and instability in the remaining patients (83 of 326 [25%]) was exhibited infrequently. We recorded 111 MET activation criteria events caused by cardiorespiratory instability in 59 patients, but MET activation for this cause occurred in only 7 patients. All MET events were detected by BSI in advance (mean, 6.3 hours) in a bimodal distribution (>6 hours and < or =45 minutes). CONCLUSIONS Cardiorespiratory instability, while uncommon and often unrecognized, was preceded by elevation of the IMS index. Continuous noninvasive monitoring augmented by IMS provides sensitive detection of early instability in patients in SDUs.
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Affiliation(s)
- Marilyn Hravnak
- School of Nursing, University of Pittsburgh, 336 Victoria Bldg, 3500 Victoria St, Pittsburgh, PA 15261, USA.
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Abstract
Intensive care medicine was for many years practiced within the four walls of an intensive care unit (ICU). Evidence then emerged that many serious adverse events in hospitals were preceded by many hours of slow deterioration, resulting in multi-organ failure and potentially preventable admissions to the ICU. Ironically, these admissions may have been prevented if the skills within the ICU had been available to the patient on the general ward at an earlier stage. The concept of a Medical Emergency Team (MET) was developed to enable staff from the ICU to rapidly identify and respond to serious illness at an earlier stage and, hopefully, prevent serious complications. Since then, other forms of rapid response and outreach systems have been developed. Increasingly, physicians working in ICUs can see the benefit of the early management of serious illness in order to improve patient outcome.
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Affiliation(s)
- Ken Hillman
- University of New South Wales; Critical Care Services, Sydney South West Area Health Service, Sydney, Australia.
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Ranji SR, Auerbach AD, Hurd CJ, O'Rourke K, Shojania KG. Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis. J Hosp Med 2007; 2:422-32. [PMID: 18081187 DOI: 10.1002/jhm.238] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND A rapid response system (RRS) consists of providers who immediately assess and treat unstable hospitalized patients. Examples include medical emergency teams and rapid response teams. Early reports of major improvements in patient outcomes led to widespread utilization of RRSs, despite the negative results of a subsequent cluster-randomized trial. PURPOSE To evaluate the effects of RRSs on clinical outcomes through a systematic literature review. DATA SOURCES MEDLINE, BIOSIS, and CINAHL searches through August 2006, review of conference proceedings and article bibliographies. STUDY SELECTION Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies reporting effects of an RRS on inpatient mortality, cardiopulmonary arrests, or unscheduled ICU admissions. DATA EXTRACTION Two authors independently determined study eligibility, abstracted data, and classified study quality. DATA SYNTHESIS Thirteen studies met inclusion criteria: 1 cluster-randomized controlled trial (RCT), 1 interrupted time series, and 11 before-after studies. The RCT showed no effects on any clinical outcome. Before-after studies showed reductions in inpatient mortality (RR = 0.82, 95% CI: 0.74-0.91) and cardiac arrest (RR = 0.73, 95% CI: 0.65-0.83). However, these studies were of poor methodological quality, and control hospitals in the RCT reported reductions in mortality and cardiac arrest rates comparable to those in the before-after studies. CONCLUSIONS Published studies of RRSs have not found consistent improvement in clinical outcomes and have been of poor methodological quality. The positive results of before-after trials likely reflects secular trends and biased outcome ascertainment, as the improved outcomes they reported were of similar magnitude to those of the control group in the RCT. The effectiveness of the RRS concept remains unproven.
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Affiliation(s)
- Sumant R Ranji
- Department of Medicine, University of California San Francisco, California 94143-0131, USA.
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Dacey MJ, Mirza ER, Wilcox V, Doherty M, Mello J, Boyer A, Gates J, Brothers T, Baute R. The effect of a rapid response team on major clinical outcome measures in a community hospital*. Crit Care Med 2007; 35:2076-82. [PMID: 17855821 DOI: 10.1097/01.ccm.0000281518.17482.ee] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the effect of a rapid response system composed primarily of a rapid response team led by physician assistants on the rates of in-hospital cardiac arrests, total and unplanned intensive care unit admissions, and hospital mortality. DESIGN Prospective, controlled, before and after trial. SETTING A 350-bed nonteaching community hospital. PATIENTS All adult patients admitted to the hospital from May 1, 2005, to October 1, 2006. INTERVENTIONS We introduced a hospital-wide rapid response system that included a rapid response team (RRT) led by physician assistants with specialized critical care training. MEASUREMENTS AND MAIN RESULTS We measured the incidence of cardiac arrests that occurred outside of the intensive care unit, total intensive care unit admissions, unplanned intensive care unit admissions, intensive care unit length of stay, and the total hospital mortality rate occurring over the study period. There were 344 RRT calls during the study period. In the 5 months before the rapid response system began, there were an average of 7.6 cardiac arrests per 1,000 discharges per month. In the subsequent 13 months, that figure decreased to 3.0 cardiac arrests per 1,000 discharges per month. Overall hospital mortality the year before the rapid response system was 2.82% and decreased to 2.35% by the end of the RRT year. The percentage of intensive care unit admissions that were unplanned decreased from 45% to 29%. Linear regression analysis of key outcome variables showed strong associations with the implementation of the rapid response system, as did analysis of variables over time. Physician assistants successfully managed emergency airway situations without assistance in the majority of cases. CONCLUSIONS The deployment of an RRT led by physician assistants with specialized skills was associated with significant decreases in rates of in-hospital cardiac arrest and unplanned intensive care unit admissions.
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Affiliation(s)
- Michael J Dacey
- Critical Care Division and the Division of Hospitalist Medicine, Kent Hospital, Warwick, RI, USA.
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McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M. Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev 2007:CD005529. [PMID: 17636805 DOI: 10.1002/14651858.cd005529.pub2] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Despite the fact that outreach and early warning systems (EWS) are an integral part of a hospital wide systems approach to improve the early identification and management of deteriorating patients on general hospital wards, the widespread implementation of these interventions in practice is not based on robust research evidence. OBJECTIVES The primary objective was to determine the impact of critical care outreach services on hospital mortality rates. Secondary objectives included determining the effect of outreach services on intensive care unit (ICU) admission patterns, length of hospital stay and adverse events. SEARCH STRATEGY The review authors searched the following electronic databases: EPOC Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) and other Cochrane databases (all on The Cochrane Library 2006, Issue 3), MEDLINE (1996-June week 3 2006), EMBASE (1974-week 26 2006), CINAHL (1982-July week 5 2006), First Search (1992-2005) and CAB Health (1990-July 2006); also reference lists of relevant articles, conference abstracts, and made contact with experts and critical care organisations for further information. SELECTION CRITERIA Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series designs (ITS) which measured hospital mortality, unanticipated ICU admissions, ICU readmissions, length of hospital stay and adverse events following implementation of outreach and EWS in a general hospital ward to identify deteriorating adult patients versus general hospital ward setting without outreach and EWS were included in the review. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data and two review authors assessed the methodological quality of the included studies. Meta-analysis was not possible due to heterogeneity. Summary statistics and descriptive summaries of primary and secondary outcomes are presented for each study. MAIN RESULTS Two cluster-randomised control trials were included: one randomised at hospital level (23 hospitals in Australia) and one at ward level (16 wards in the UK). The primary outcome in the Australian trial (a composite score comprising incidence of unexpected cardiac arrests, unexpected deaths and unplanned ICU admissions) showed no statistical significant difference between control and medical emergency team (MET) hospitals (adjusted P value 0.640; adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16). The UK-based trial found that outreach reduced in-hospital mortality (adjusted OR 0.52; 95% CI 0.32 to 0.85) compared with the control group. AUTHORS' CONCLUSIONS The evidence from this review highlights the diversity and poor methodological quality of most studies investigating outreach. The results of the two included studies showed either no evidence of the effectiveness of outreach or a reduction in overall mortality in patients receiving outreach. The lack of evidence on outreach requires further multi-site RCT's to determine potential effectiveness.
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Affiliation(s)
- J McGaughey
- Queen's University Belfast, School of Nursing and Midwifery, Belfast, UK.
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Price RJ, Cuthbertson BH, Cairns CJ. The findings of the International Conference on Medical Emergency Teams are biased and misleading. Crit Care Med 2007; 35:992-3. [PMID: 17421116 DOI: 10.1097/01.ccm.0000257474.01932.2f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND A high incidence of preventable adverse events and deaths in hospitals has triggered initiatives to improve the quality of care of acutely ill in-hospital patients. System changes involving the introduction of medical emergency teams, outreach services or rapid response teams are an integral part of these initiatives. The rationale for implementing a designated team is that early recognition and rapid institution of adequate therapy for the deteriorating patient can improve outcome. The concept of bringing intensive care expertise to any acutely ill patient irrespective of location within the hospital is envisioned as "critical care without walls". METHODS Studies were identified by a PubMed search and cited references in key publications provided additional material including www-resources. More than 80 studies were identified and selected for review, however, no formal search strategy for a systematic review or meta-analysis was attempted. Only studies published in English were considered. RESULTS Several non-randomized, before-and-after cohort studies demonstrate that implementation of medical emergency teams and equivalents can reduce the incidence of cardiac arrests, unexpected deaths, and unplanned intensive care admissions. However, one recent randomized, controlled trial of medical emergency teams failed to demonstrate any differences in outcomes. CONCLUSION Several key operational issues need to be addressed before introducing medical emergency response teams based on current evidence. These issues include differences in healthcare systems and performance, patient case-mix, resources available, composition of the teams and calling criteria, and strategies for education, audit and governance.
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Affiliation(s)
- A Aneman
- Intensive Care Unit, Liverpool Hospital, Sydney South-West Area Health Service, Sydney, Australia.
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Top WMC, Schultz MJ, Jurrjens FH, Rommes JH, Spronk PE. Workload and main activities of consultative ICU nurses: long-term experience in a large teaching hospital in the Netherlands. Acta Anaesthesiol Scand 2006; 50:1187-91. [PMID: 17067321 DOI: 10.1111/j.1399-6576.2006.01143.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Early recognition and prompt treatment of deteriorating patients outside the intensive care unit (ICU) improves hospital survival. Over the past decade, consultative services have been implemented in many institutions. This service is frequently performed by ICU nurses, while little information is available on the workload and type of activities these ICU nurses actually perform. METHODS In 1995, a consultative ICU nurse-driven service was introduced in a large teaching hospital in the Netherlands. In this descriptive study, we determined types of consultation, time consumed per visit, and main interventions during these activities. RESULTS During the study period, 9144 consultations in 4365 patients were performed. While the number of 'scheduled' visits (visits of patients after discharge from the ICU) was reasonably variable during the study period, the number of 'on demand' visits (visits demanded by non-ICU personnel) increased gradually, especially during the first years. At the end of the observation period, approximately half of the visits were 'on demand' in the non-ICU wards. The mean number of consultations per patient dropped gradually over the whole period, from 4.02 in 1996 to 1.54 in 2004. The total workload was approximately half an hour per day; visits were combined with regular activities of the ICU team. Tracheal suctioning was among the most frequent activities during consultation (approximately 90% of all visits). CONCLUSION Consultative ICU nurses play a growing role in bridging the gap between the ICU and non-ICU departments in our hospital. Workload is acceptable.
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Affiliation(s)
- W M C Top
- Gelre Hospitals, Lukas Site, Apeldoorn, the Netherlands
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