Use of medical emergency team responses to reduce hospital cardiopulmonary arrests

Rapid Response Systems

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.

Nurse-led medical emergency response reduces code blue team activations in non-hospitalized patients

Objective

We describe the creation of a two-tier emergency response system with a nurse-led first responder program titled "MET-RN" (Medical Emergency Team-Registered Nurse) created for ambulatory settings supported by a critical care code blue team for escalation of care. This observational study evaluated the clinical characteristics and effects of a MET-RN program on the code blue response.

Methods

A retrospective review of the MET-RN response data was assessed from January 2016 to June 2021. Data collected included time of call, call location, patient comorbidities, triage category (minor, urgent, or emergent), activation trigger, interventions performed, duration of the event, and patient disposition. In instances where the patient was admitted to the hospital, the discharge diagnosis and emergency department (ED) triage score were collected. Differences were tested using analysis of variance (ANOVA) F-tests, with Tukey post-hoc testing where applicable.

Results

MET-RN responded to 6,564 encounters from January 2016 to June 2021. The most frequent trigger call was dizziness/lightheadedness, with a prevalence of 12.0%. 33.9% of the patients seen by MET-RN were transported to the ED for further evaluation. Establishing a MET-RN system led to an estimated median of 58.3% reduction in utilization of the code blue team per quarter.

Conclusion

The creation of MET-RN first responder system enabled the ambulatory areas to receive minor, urgent, and emergent patient care support, leading to a decrease in utilization of the code blue team for the hospital. A two-tiered response system resulted in an improved allocation of hospital resources and kept critical care teams in high-acuity areas while maintaining patient safety.

Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023

RATIONALE

Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients.

OBJECTIVES

To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients.

PANEL DESIGN

The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines.

METHODS

We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs).

RESULTS

The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system.

CONCLUSIONS

The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Effects of a Rapid Response Team on Patient Outcomes: A Systematic Review

BACKGROUND

Despite the widespread adoption of the rapid response team (RRT) by many hospitals, questions remain regarding their effectiveness in improving several aspects of patient outcomes, such as hospital mortality, cardiopulmonary arrests, unplanned intensive care unit (ICU) admissions, and length of stay (LOS).

OBJECTIVES

To conduct a systematic review to understand the rapid response team's (RRT) effect on patient outcomes.

METHODS

A systematic search was conducted using PubMed, Cochrane, Embase, CINAHL, Web of Science, and two trial registers. The studies published up to May 6, 2022, from the inception date of the databases were included. Two researchers filtered the title, abstract and full text. The Version 2 of the Cochrane Risk of Bias tool and Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool were used separately for randomized and non-randomized controlled trials for quality appraisal.

RESULTS

Sixty-one eligible studies were identified, four randomized controlled trials(RCTs), four non-randomized controlled trials, six interrupted time-series(ITS) design , and 47 pretest-posttest studies. A total of 52 studies reported hospital mortality, 51 studies reported cardiopulmonary arrests, 18 studies reported unplanned ICU admissions and ten studies reported LOS.

CONCLUSION

This systematic review found the variation in context and the type of RRT interventions restricts direct comparisons. The evidence for improving several aspects of patient outcomes was inconsistent, with most studies demonstrating that RRT positively impacts patient outcomes.

Medication-related Medical Emergency Team activations: a case review study of frequency and preventability

OBJECTIVES

Despite recognition of clinical deterioration and medication-related harm as patient safety risks, the frequency of medication-related Rapid Response System activations is undefined. We aimed to estimate the incidence and preventability of medication-related Medical Emergency Team (MET) activations and describe the associated adverse medication events.

METHODS

A case review study of consecutive MET activations at two acute, academic teaching hospitals in Melbourne, Australia with mature Rapid Response Systems was conducted. All MET activations during a 3-week study period were assessed for a medication cause including identification of the contributing adverse medication event and its preventability, using validated tools and recognised classification systems.

RESULTS

There were 9439 admissions and 628 MET activations during the study period. Of these, 146 (23.2%) MET activations were medication related: an incidence of 15.5 medication-related MET activation per 1000 admissions. Medication-related MET activations occurred a median of 46.6 hours earlier (IQR 22-165) in an admission than non-medication-related activations (p=0.001). Furthermore, this group also had more repeat MET activations during their admission (p=0.021, OR=1.68, 95% CI 1.09 to 2.59). A total of 92 of 146 (63%) medication-related MET activations were potentially preventable. Tachycardia due to omission of beta-blocking agents (10.9%, n=10 of 92) and hypotension due to cumulative toxicity (9.8%, n=9 of 92) or inappropriate use (10.9%, n=10 of 92) of antihypertensives were the most common adverse medication events leading to potentially preventable medication-related MET activations.

CONCLUSIONS

Medications contributed to almost a quarter of MET activations, often early in a patient's admission. One in seven MET activations were due to potentially preventable adverse medication events. The most common of these were omission of beta-blockers and clinically inappropriate antihypertensive use. Strategies to prevent these events would increase patient safety and reduce burden on the MET.

Piloting a Nurse-Led Critical Care Outreach Service to Pre-Empt Medical Emergency Team Calls and Facilitate Staff Learning

A nurse-led critical care outreach service (NLCCOS) can support staff education and decision making in the wards, managing at-risk patients with ward nurses to avoid further deterioration. We aimed to investigate the characteristics of patients identified as at-risk, the types of treatments they required to prevent deterioration, the education initiated by the NLCCOS, and the perceived experiences of ward nurses. This prospective observational pilot study using mixed methods took place in one medical and one surgical ward at a university hospital in Denmark. Participants were patients nominated as at-risk by head nurses in each ward, the ward nurses, and nurses from the NLCCOS. In total, 100 patients were reviewed, 51 medical and 49 surgical patients, over a six-month period. Most patients (70%) visited by the NLCCOS had a compromised respiratory status, and ward nurses received teaching and advice regarding interventions. Sixty-one surveys were collected from ward nurses on their learning experience. Over 90% (n = 55) of nurses believed they had learned from, and were more confident with, managing patients following the experience. The main educational areas were respiratory therapy, invasive procedures, medications, and benefits of mobilization. Further research needs to measure the impact of the intervention on patient outcomes and MET call frequency over time in larger samples.

Programme of triple-I mediator education (TIME) to improve medical disputes in clinical settings in Taiwan: a Delphi study

OBJECTIVES

To establish a training programme to cultivate trainee mediation skills through time investment, skill incorporation and formation of in-house mediation services.

DESIGN

A four-round consensus conference was conducted by a number of seasoned experts selected in the manner of purposive sampling to determine core competences and relevant curricula through the modified Delphi process.

SETTING

Responses collected from enrolled experts through four rounds of the Delphi process from 11 November 2018 to 17 May 2019.

PARTICIPANTS

Onboard seasoned mediators with different specialties.

OUTCOME MEASURES

Items with a median rating of 4 or more on a Likert scale of 1-7 points and 70% or more in agreement were identified as core competence and curricula.

RESULTS

Eleven enrolled experts reached the consensus about the training syllabus based on the 4-round agreement with four pillars of core competence, including 'knowledge base of law', 'internalisation of the denotative and connotative meanings of care', 'effective, smooth and timely communication' and 'conflict resolution'. To grasp the dynamics and diversity of medical disputes on target, it is necessary to have sufficient knowledge and skills. We arrange our course in the order of teaching materials with pure didactics in the former two and with mixed contents comprising lectures and field exercises in the rest two.

CONCLUSIONS

The sample developed a syllabus to train apprentices to take intermediate responses to medical disputes through the skills of conflict resolution and establishment of effective communication to improve the relationship between patients/relatives and medical staff, as a result of eventually reducing the conversion rate from dispute into litigation or alternative pathway. Policy-makers in healthcare and top management in healthcare institutions can use this syllabus to guide their future education and training programme.

Relationship between Time of Day of Medical Emergency Team Activations and Outcomes of Hospitalized Pediatric Patients

This study was conducted to investigate whether outcomes of medical emergency team (MET) activations differ by time of day of in-hospitalized pediatric patients. This is a retrospective cohort study. Data were extracted from the charts of 846 patients (with one or more MET activations) over a 5-year period. It was conducted at Children's Hospital of Eastern Ontario, a tertiary pediatric hospital in Ottawa, Canada, affiliated with University of Ottawa. Patients included children <18 years, admitted to a pediatric ward, who experienced a MET activation between January 1, 2016 and December 31, 2020. We excluded patients reviewed by the MET during a routine follow-up, planned pediatric intensive care unit (PICU) admissions from the ward, and MET activation in out-patient settings, post-anesthesia care unit, and neonatal intensive care unit. There was no intervention. A total of 1,230 MET encounters were included as part of the final analysis. Daytime (08:00–15:59) MET activation was associated with increased PICU admission (25.3%, p = 0.04). There was some evidence of a higher proportion of critical deterioration events (CDEs) during daytime MET activation; however, this did not reach statistical significance (24%, p = 0.09). The highest MET dosage occurred during the evening hours, 16:00 to 23:59 (15/1,000 admissions), and it was lowest overnight, 00:00 to 07:59 (8.8/1,000 admissions, p < 0.001). This period of lowest MET dosage immediately preceded the highest likelihood of PICU admission (08:00, 37.5%) and CDE (09:00, 30.2%). Following the period of lowest MET activity overnight, MET activations during early daytime hours were associated with the highest likelihood of unplanned PICU admission and CDEs. This work identifies potential high-risk periods for undetected critical deterioration and targets for future quality improvement.

Incidence of preventable cardiopulmonary arrest in a mature part-time rapid response system: A prospective cohort study

Background

The purpose of a rapid response system (RRS) is to reduce the incidence of preventable cardiopulmonary arrests (CPAs) and patient deterioration in general wards. The objective of this study is to investigate the incidence and temporal trends of preventable CPAs and determine factors associated with preventable CPAs in a hospital with a mature RRS.

Methods

This was a single-center prospective cohort study of all CPAs occurring in the general ward between March 2017 and June 2020. The RRS operates from 07:00 to 23:00 on weekdays and from 07:00 to 12:00 on Saturdays. All CPAs were reviewed upon biweekly conference, and a panel of intensivists judged their preventability. Trends of preventable CPAs were analyzed using Poisson regression models and factors associated with preventable CPAs were analyzed using multivariable logistic regression.

Results

There were 253 CPAs over 40 months, and 64 (25.3%) of these were preventable. The incidence rate of CPAs was 1.07 per 1000 admissions and that of preventable CPAs was 0.27 per 1000 admissions. The number of preventable CPAs decreased by 24% each year (incidence rate ratio = 0.76; p = 0.039) without a change in the total CPA incidence. The most common contributor to the preventability was delayed response from physicians (n = 41, 64.1%). A predictable CPA with a pre-alarm sign had increased odds in the occurrence of preventable CPAs, while a cardiac cause of CPAs and RRS operating hours had decreased odds in terms of occurrence of preventable CPA.

Conclusion

Our study showed that one-fourth of all CPAs occurring in the general wards were preventable, and these arrests decreased each year. A mature RRS can evolve to reduce preventable CPAs with regular self-evaluation. Efforts should be directed at improving physicians’ response time since a delay in their response was the most common cause of preventable CPAs.

CoBRA: COde Blue Retrospective Audit in a Metropolitan Hospital

BACKGROUND

In-hospital cardiac arrest (IHCA) is an uncommon but challenging problem. This study aims to investigate the management and outcomes of IHCA, and investigate the effect of introducing a Medical Emergency Team (MET) on IHCA prevalence.

METHODS

Retrospective medical record review of 176 adult IHCA episodes at Box Hill Hospital, a university-affiliated public hospital in metropolitan Melbourne, from July 2012 to June 2017. Inpatients receiving cardiopulmonary resuscitation for IHCA, in inpatient wards, intensive care unit, cardiac catheterisation laboratory, and operating theatres, were included. Data collected included demographics, resuscitation management, and outcomes. Average treatment effect (ATE) was derived from margins estimates and linear regression fitted to hospital outcome, adjusted for IHCA factors. An exponentially-weighed moving average control chart was used to explore IHCA prevalence over time.

RESULTS

65.3% of IHCA patients died in hospital. IHCA prevalence was unchanged after the introduction of a dedicated MET service. Factors associated with higher likelihood of survival to discharge were initial cardiac of rhythm ventricular tachycardia (VT) (ATE 0.10 (95%CI = -0.03-0.25)) or ventricular fibrillation (VF) (ATE 0.28 (95% CI=0.11-0.46)), cardiac monitoring at time of arrest (ATE 0.06 (95%CI = -0.04-0.16)), and time to return of spontaneous circulation (ATE 0.023 (95%CI=0.015-0.031)).

CONCLUSION

IHCA is uncommon and is associated with high mortality. IHCA prevalence was unchanged after the introduction of a dedicated MET service. Factors associated with improved survival to hospital discharge were initial rhythm VT or VF, cardiac monitoring, and shorter resuscitation times. This article is protected by copyright. All rights reserved.

Strategies for successful implementation and permanent maintenance of a rapid response system

Rapid response systems (RRSs) have been introduced to intervene with patients experiencing non-code medical emergencies and operate widely around the world. An RRS has four components: an afferent limb, an efferent limb, quality improvement, and administration. A proper triggering system, a hospital culture that embraces the RRS from the afferent limb, experienced primary responders, and dedicated physicians from the efferent limb are key for successful implementation. After initial implementation, quality improvement through objective outcome measures and self-evaluation are crucial, which lead to a better outcome when this process is well performed. Furthermore, better outcomes lead to more investment, which is essential for effective development of the system. The RRS is successfully maintained when these four components are closely interconnected.

European Resuscitation Council Guidelines 2021: Systems saving lives

The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.

Quels sont le fonctionnement, les caractéristiques, les effets et les modalités d’implantation des équipes d’intervention rapide ? Une revue de la littérature

Introduction&#160;: Hospitalized patients are at risk of unrecognized clinical deterioration that may lead to adverse events.Context&#160;: Rapid Response Teams (RRTs) exist around the world as a strategy to improve patient safety.Objective&#160;: To explore how RRTs work, their characteristics, impacts, and methods of implementation.Design&#160;: Literature review.Method&#160;: Consultation of the databases CINAHL, MEDLINE, PUBMED, COCHRANE library, SCOPUS, and PROQUEST Dissertations and Theses. Keywords&#160;: &#8220;health care team&#8221; and &#8220;rapid response team&#8221;.Results&#160;: 121 articles were included. The collected data were divided into five categories&#160;: 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&#160;: Although there are many articles related to RRTs, it appears that&#160;: 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&#8217; and patients&#8217; perceptions of RRTs are not well studied, and 5) more studies are needed on the best way to implement an RRT.Conclusion&#160;: 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&#8217; and patients&#8217; perceptions of RRTs, and on the factors that influence the success or failure of the implementation of an RRT.

Reduction of in-hospital cardiac arrest with sequential deployment of rapid response team and medical emergency team to the emergency department and acute care wards

Purpose

This study aimed to determine if sequential deployment of a nurse-led Rapid Response Team (RRT) and an intensivist-led Medical Emergency Team (MET) for critically ill patients in the Emergency Department (ED) and acute care wards improved hospital-wide cardiac arrest rates.

Methods

In this single-center, retrospective observational cohort study, we compared the cardiac arrest rates per 1000 patient-days during two time periods. Our hospital instituted a nurse-led RRT in 2012 and added an intensivist-led MET in 2014. We compared the cardiac arrest rates during the nurse-led RRT period and the combined RRT-MET period. With the sequential approach, nurse-led RRT evaluated and managed rapid response calls in acute care wards and if required escalated care and co-managed with an intensivist-led MET. We specifically compared the rates of pulseless electrical activity (PEA) in the two periods. We also looked at the cardiac arrest rates in the ED as RRT-MET co-managed patients with the ED team.

Results

Hospital-wide cardiac arrests decreased from 2.2 events per 1000 patient-days in the nurse-led RRT period to 0.8 events per 1000 patient-days in the combined RRT and MET period (p-value = 0.001). Hospital-wide PEA arrests and shockable rhythms both decreased significantly. PEA rhythms significantly decreased in acute care wards and the ED.

Conclusion

Implementing an intensivist-led MET-RRT significantly decreased the overall cardiac arrest rate relative to the rate under a nurse-led RRT model. Additional MET capabilities and early initiation of advanced, time-sensitive therapies likely had the most impact.

Derivation and validation of modified early warning score plus SpO2/FiO2 score for predicting acute deterioration of patients with hematological malignancies

BACKGROUND/AIMS

Scoring systems play an important role in predicting intensive care unit (ICU) admission or estimating the risk of death in critically ill patients with hematological malignancies. We evaluated the modified early warning score (MEWS) for predicting ICU admissions and in-hospital mortality among at-risk patients with hematological malignancies and developed an optimized MEWS.

METHODS

We retrospectively analyzed derivation cohort patients with hematological malignancies who were managed by a medical emergency team (MET) in the general ward and prospectively validated the data. We compared the traditional MEWS with the MEWS plus SpO2/FiO2 (MEWS_SF) score, which were calculated at the time of MET contact.

RESULTS

In the derivation cohort, the areas under the receiver-operating characteristic (AUROC) curves were 0.81 for the MEWS (95% confidence interval [CI], 0.76 to 0.87) and 0.87 for the MEWS_SF score (95% CI, 0.87 to 0.92) for predicting ICU admission. The AUROC curves were 0.70 for the MEWS (95% CI, 0.63 to 0.77) and 0.76 for the MEWS_SF score (95% CI, 0.70 to 0.83) for predicting in-hospital mortality. In the validation cohort, the AUROC curves were 0.71 for the MEWS (95% CI, 0.66 to 0.77) and 0.83 for the MEWS_SF score (95% CI, 0.78 to 0.87) for predicting ICU admission. The AUROC curves were 0.64 for the MEWS (95% CI, 0.57 to 0.70) and 0.74 for the MEWS_SF score (95% CI, 0.69 to 0.80) for predicting in-hospital mortality.

CONCLUSION

Compared to the traditional MEWS, the MEWS_SF score may be a useful tool that can be used in the general ward to identify deteriorating patients with hematological malignancies.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Diurnal Variation in Medical Emergency Team Calls at a Tertiary Care Children's Hospital

Medical emergency teams (METs) bring critical care expertise to the bedsides of hospital ward patients who may be deteriorating. Diurnal variation in MET activation rates may identify inconsistencies in the detection of patients needing intervention. We aimed to determine whether such variation exists at our tertiary care children's hospital.

Methods

In this retrospective cohort study, we collected data including date and time of MET and disposition following MET for all inpatients at Cincinnati Children's Hospital Medical Center with a MET call between January 2008 and May 2014. The analysis compared the MET rate between days and nights, weekdays and weekends, and before and after nursing shift change.

Results

The number of METs per hour varied throughout the day. More METs were called during the day than at night (0.7 calls/shift ± 0.95 vs 0.6 ± 0.9, P < 0.001). There were also more METs per day on weekdays than weekends (1.4 ± 1 calls/d vs 1.2 ± 1, P < 0.001). Daytime METs were more likely to lead to transfer to the intensive care unit or operating room than those called at night (61.9% vs. 52.9%, P < 0.001). MET activation rates did not differ significantly in the 2 hours before nursing shift change compared to the 2 hours after.

Conclusions

At our large tertiary care children's hospital, there are both diurnal variations and variations across weekdays versus weekends in the MET activation rate. This difference may indicate variations in our ability to detect deteriorating patients on the wards and be further studied.

Opportunities for machine learning to improve surgical ward safety

BACKGROUND

Delayed recognition of decompensation and failure-to-rescue on surgical wards are major sources of preventable harm. This review assimilates and critically evaluates available evidence and identifies opportunities to improve surgical ward safety.

DATA SOURCES

Fifty-eight articles from Cochrane Library, EMBASE, and PubMed databases were included.

CONCLUSIONS

Only 15-20% of patients suffering ward arrest survive. In most cases, subtle signs of instability often occur prior to critical illness and arrest, and underlying pathology is reversible. Coarse risk assessments lead to under-triage of high-risk patients to wards, where surveillance for complications depends on time-consuming manual review of health records, infrequent patient assessments, prediction models that lack accuracy and autonomy, and biased, error-prone decision-making. Streaming electronic heath record data, wearable continuous monitors, and recent advances in deep learning and reinforcement learning can promote efficient and accurate risk assessments, earlier recognition of instability, and better decisions regarding diagnosis and treatment of reversible underlying pathology.

Development and Evaluation of a Cognitive Aid Booklet for Use in Rapid Response Scenarios

INTRODUCTION

Rapid response teams (RRTs) have become ubiquitous among hospitals in North America, despite lack of robust evidence supporting their effectiveness. Many RRTs do not yet use cognitive aids during these high-stakes, low-frequency scenarios, and there are no standardized cognitive aids that are widely available for RRTs on medicine patients. We sought to design an emergency manual to improve resident performance in common RRT calls.

METHODS

Residents from the New York University School of Medicine Internal Medicine Residency Program were asked to volunteer for the study. The intervention group was provided with a 2-minute scripted informational session on cognitive aids as well as access to a cognitive aid booklet, which they were allowed to use during the simulation.

RESULTS

Resident performance was recorded and scored by a physician who was blinded to the purpose of the study using a predefined scoring card. Residents in the intervention group performed significantly better in the simulated RRT, by overall score (mean score = 7.33/10 and 6.26/10, respectively, P = 0.02), and by performance on the two critical interventions, giving the correct dose of naloxone (89% and 39%, respectively, P < 0.001) and checking the patient's blood glucose level (93% and 52%, respectively, P = 0.001).

CONCLUSIONS

In a simulated scenario of opiate overdose, internal medicine residents who used a cognitive aid performed better on critical tasks than those residents who did not have a cognitive aid. The use of an appropriately designed cognitive aid with sufficient education could improve performance in critical scenarios.

Nurses' just-in-time training for clinical deterioration: Development, implementation and evaluation

BACKGROUND

'Just-in-time training' is an innovative approach to nursing education. It has demonstrated positive outcomes in other industries, such as manufacturing and aviation, but it has limited published application in the acute-care setting.

OBJECTIVES

We aimed to implement and evaluate a nursing 'just-in-time training' program for the recognition and response to patient deterioration.

DESIGN

To promote consistency, one Clinical Deterioration Educator provided education to nursing staff in both recognising the need for escalation and providing subsequent care for the deteriorating ward patient. Nurses' perception of the 'just-in-time training' program was determined using electronic questionnaire responses. Medical Emergency Team call prevalence and outcome data was compared before and after the program implementation for further evaluation.

SETTING

The 'just-in-time training' program was implemented in a 508-bed acute metropolitan private hospital over a 12-month period. Education was provided in general medical and surgical wards, not specialty areas.

PARTICIPANTS

Nurses received the just-in-time training based on their patients' perceived risk of deterioration, therefore, participants are not randomised.

METHODS

A quantitative research study investigated nurses' self-perceived confidence after receiving just-in-time training. Medical Emergency Team call frequency data was also examined to identify trends.

RESULTS

The 'just-in-time training' program consisted of 534 bedside nursing encounters over 12 months. During the study, the need for the educator to recommend that nurses escalate care reduced in prevalence from 20% to 5.5%. Questionnaire responses demonstrated a self-perceived confidence following intervention of 4.32/5.0. Medical Emergency Team call prevalence, per 1000 patient bed days, increased from 13.6 pre-intervention to 15.4 post-intervention.

CONCLUSIONS

Just-in-time training' can be effectively implemented to educate ward nursing staff in recognising and responding to the deteriorating patient. The program is well received by nursing staff and leads to high self-perceived confidence to recognise and appropriately care for a deteriorating patient.

The effectiveness of a national early warning score as a triage tool for activating a rapid response system in an outpatient setting: A retrospective cohort study

Rapid response system (RRS) efficacy and national early warning score (NEWS) performances have largely been reported in inpatient settings, with few such reports undertaken in outpatient settings.This study aimed to investigate NEWS validity in predicting poor clinical outcomes among outpatients who had activated the RRS using single-parameter criteria.A single-center retrospective cohort studyFrom April 1, 2014 to November 30, 2017 in an urban 350-bed referral hospital in JapanWe collected patient characteristics such as activation triggers, interventions, arrival times, dispositions, final diagnoses, and patient outcomes. Poor clinical outcomes were defined as unplanned intensive care unit transfers or deaths within 24 hours. Correlations between the NEWS and clinical outcomes at the time of deterioration and disposition were analyzed.Among 31 outpatients, the NEWS value decreased significantly after a medical emergency team intervention (median, 8 vs 4, P < .001). The difference in the NEWS at the time of deterioration and at disposition was significantly less in patients with poor clinical outcomes (median 3 vs 1.5, P = .03). The area under the curve (AUC) for the NEWS high-risk patient group at the time of deterioration for predicting hospital admission was 0.85 (95% confidence interval [CI], 0.67-1.0), while the AUC for the NEWS high-risk patient group at disposition for predicting poor clinical outcomes was 0.83 (95% CI, 0.62-1.0).The difference between the NEWS at the time of deterioration and at disposition might usefully predict admissions and poor clinical outcomes in RRS outpatient settings.

Increasing the Number of Medical Emergency Calls Does Not Improve Hospital Mortality

OBJECTIVES

Medical emergency teams were established to rescue patients experiencing clinical deterioration thus preventing cardiac arrest and unexpected hospital mortality. Although hospitals are encouraged to increase emergency calling rates to improve in-hospital mortality, there are increasing concerns about the impact these calls have on the workload of the teams and the skill levels on the general wards. We set out to examine the relationship between emergency calling rates and adjusted in-hospital mortality.

DESIGN

Retrospective analysis of prospectively collected patient and emergency call data.

SETTING

Tertiary, metropolitan, and regional hospitals in the State of Victoria, Australia.

PATIENTS

Consecutive patients discharged from 1) St Vincent's Hospital Melbourne from January 2008 to June 2016 and 2) 15 Victorian hospitals from July 2010 to June 2015.

MEASUREMENTS AND MAIN RESULTS

We studied 441,029 patients from St Vincent's Hospital Melbourne. Median age was 61.0 years (interquartile range, 45-74 yr), 57.2% were men, and 0.70% died; monthly emergency calling rates varied between 9.21 and 30.69 (median 18.4) per 1,000 discharges. In-hospital mortality adjusted for age, gender, emergency status, same day admission, year of discharge, and Charlson Comorbidity Index was not reduced by higher calling rates in the month of discharge (odds ratio, 1.019; 95% CI, 1.008-1.031). We then examined 3,339,789 discharges from 15 Victorian hospitals with median age 61 years (interquartile range, 43-74 yr), 51.4% men, and hospital mortality 0.83% where yearly emergency calling rates varied from 18.46 to 33.40 (median, 25.75) per 1,000 discharges. Again, adjusted mortality was not reduced by higher calling rates in the year of discharge (odds ratio, 1.003; 95% CI, 1.001-1.006).

CONCLUSIONS

With adjustment for patient factors, illness, and comorbidities, increased emergency calling rates were not associated with reduced in-hospital mortality. Efforts to increase calling rates do not seem warranted.

Rapid Response and Cardiac Arrest Teams: A Descriptive Analysis of 103 American Hospitals

Despite improvements in the management of in-hospital cardiac arrest over the past decade, in-hospital cardiac arrest continues to be associated with poor prognosis. This has led to the development of rapid response systems, hospital-wide efforts to improve patient outcomes by centering on prompt identification of decompensating patients, expert clinical management, and continuous quality improvement of processes of care. The rapid response system may include cardiac arrest teams, which are centered on identification and treatment of patients with in-hospital cardiac arrest. However, few evidence-based guidelines exist to guide the formation of such teams, and the degree of their variation across the United States has not been well described.

DESIGN

Descriptive cross-sectional, internet-based survey.

SETTING

Cohort of preidentified clinicians involved in their hospital's adult rapid response system across the United States.

SUBJECTS

Clinicians who had been identified by study team members using personal and professional contacts over a 7-month period from June 2018 to December 2018.

INTERVENTIONS

An 80-item survey was developed by the investigators. It sought information on the afferent (identification and notification of providers) and efferent (response of providers to patient) limbs of the rapid response system, as well as management of patients post in-hospital cardiac arrest.

MEASUREMENTS AND MAIN RESULTS

One-hundred fourteen surveys were distributed. Of these, 109 (96%) were completed. Six were duplicates and were excluded, leaving a total of 103 surveys from 103 hospitals in 30 states. Seventy-six percent of hospitals were academic, 30% were large hospitals (> 750 inpatient beds), and 58% had large ICUs (> 50 ICU beds). We found wide variation in the structure and function in both the afferent and efferent limbs of the rapid response system. The majority of hospitals had a rapid response team and a cardiac arrest team. Most rapid response teams contained a provider, a critical care nurse, and a respiratory therapist. In hospitals with training programs in internal medicine, anesthesia, emergency medicine, or critical care, 45% of rapid response teams and 75% of cardiac arrest teams were led by trainees, with inconsistent attending presence. Targeted temperature management and coronary catheterization were widely used post in-hospital cardiac arrest, but indications varied considerably.

CONCLUSIONS

We have demonstrated substantial variation in the structure and function of rapid response systems as well as in management of patients during and after in-hospital cardiac arrest.

The rapid response system: an integrative review

Background: Clinical deterioration and adverse events in hospitals is an increasing cause for concern. Rapid response systems have been widely implemented to identify deteriorating patients. Aim: We aimed to examine the literature highlighting major historical trends leading to the widespread adoption of rapid response systems, focussing on Australian issues and identifying future focus areas. Method: Integrative literature review including published and grey literature. Results: Seventy-eight sources including journal articles and Australian government matierlas resulted. Pertinent themes were the increasing acuity and aging of the population, importance of hospital cultures, the emerging role of the consumer, and proliferation, evolution and standardisation of rapid response systems. Discussion: Translating evidence to usual care practice is challenging and strongly driven by local factors and political imperatives. Conclusion: Rapid response systems are complex interventions requiring consideration of contextual factors at all levels. Appropriate resources, a skilled workforce and positive workplace cultures are needed for these systems to reach their full potential.

Perioperative intensive care medicine

Surgery represents one of the main therapeutic references in the world, affording greater survival and life expectancy for many patients. In general, the estimated postoperative mortality is low (around 1-4%). Thirteen percent of the surgical procedures have a high risk of complications, accounting for 80% of all postoperative deaths. Recently, there have been significant advances related to organizational aspects, new anesthetic and surgical techniques, prognostic scales, perioperative management and greater participation and involvement of the patient. This new series of Medicina Intensiva will address fundamental aspects of how Departments of Intensive Care Medicine can add value to the surgical process, in a coordinated manner with other services. Institutional policies are required to ensure the detection of patients at risk in hospitalization wards, with early admission to the ICU of those patients in whom admission is indicated, adapting the treatment in the ICU and optimizing the criteria for discharge. The detection and prevention of post-ICU syndrome in patients and relatives, and the follow-up of ICU discharge and hospitalization in a multidisciplinary manner can reduce the sequelae among critical surgical patients, improving the outcomes and quality of life, and restoring the patient to society. In future publications of this series directed to the surgical patient, updates will be provided on the perioperative management of some of the most complex surgeries.

Characterising variation in composition and activation criteria of rapid response and cardiac arrest teams: a survey of Medicare participating hospitals in five American states

OBJECTIVES

To characterise the variation in composition, leadership, and activation criteria of rapid response and cardiac arrest teams in five north-eastern states of the USA.

DESIGN

Cross-sectional study consisting of a voluntary 46-question survey of acute care hospitals in north-eastern USA.

SETTING

Acute care hospitals in New York, New Jersey, Rhode Island, Vermont, and Pennsylvania.

PARTICIPANTS

Surveys were completed by any member of the rapid response team (RRT) with a working knowledge of team composition and function. Participants were all Medicare-participating acute care hospitals, including teaching and community hospitals as well as hospitals from rural, urban and suburban areas.

RESULTS

Out of 378 hospitals, contacts were identified for 303, and 107 surveys were completed. All but two hospitals had an RRT, 70% of which changed members daily. The most common activation criteria were clinical concern (95%), single vital sign abnormalities (77%) and early warning score (59%). Eighty one per cent of hospitals had a dedicated cardiac arrest team.RRT composition varied widely, with respiratory therapists, critical care nurses, physicians and nurse managers being the most likely to attend (89%, 78%, 64% and 51%, respectively). Consistent presence of critical care physicians was uncommon and both cardiac arrest teams and teams were frequently led by trainee physicians, often without senior supervision.

CONCLUSIONS

As the largest study to date in the USA, we have demonstrated wide heterogeneity, rapid team turnover and a lack of senior supervision of RRT and cardiac arrest teams. These factors likely contribute to the mixed results seen in studies of RRTs.

What nurses involved in a Medical Emergency Teams consider the most vital areas of knowledge and skill when delivering care to the deteriorating ward patient. A nurse-oriented curriculum development project

INTRODUCTION

Critical care nurses have been involved in Rapid Response Teams since their inception, particularly in medically led RRTs, known as Medical Emergency Teams. It is assumed that critical care skills are required to escalate care for the deteriorating ward patient. However, evidence to support critical care nurses' involvement in METs is anecdotal. Currently, little is known about the educational requirements for nurses involved in RRT or METs.

OBJECTIVES

We aimed to identify and describe what nurses involved in a MET consider the most vital areas of knowledge and skill when delivering care to the deteriorating ward patient.

METHODS

An exploratory descriptive design was used and data was collected at a session of the Australian and New Zealand Intensive Care Society Rapid Response Team (ANZICS-RRT) Conference held at The Gold Coast, Australia in July 2015. All conference delegates were eligible to take part. Conference delegates totalled 293; 194 nurses, 89 doctors and 10 allied health professionals. Data collection took place in three phases, over a 90-minute period. First, demographic data were collected from all participants at the start of data collection. These data were collected using paper-based surveys. Second, extended response surveys; that is, paper-based surveys that asked open-ended questions to elicit free text responses, were used to collect participants' individual responses to the question: "What are the specific theoretical knowledge, skills and behavioural attributes required in a curricula to prepare nurses to be high functioning members of a MET?" Demographic, educational and work characteristics were descriptively analysed using SPSS (version 22). Participants perceptions of what knowledge, skills and attributes are required for nurses to recognise and respond to clinical deterioration were thematically analysed.

RESULTS

Participants were predominantly female (88.3%, n = 91) with 54.4% (n = 56) holding a Bachelor of Nursing. Participants had a median of 20 years (IQR 16) experience as RNs, and a median of 14 years (IQR 13) experience in critical care. Participants formed part of METs frequently, with nearly half the cohort seeing clinically deteriorating patients more than once per day (37.9%, n = 33) or daily (10%, n = 9). Thematic analysis of survey responses revealed four main themes desired in Rapid Response Team Curricula: Clinical Deterioration Theory, Clinical Deterioration Skills, Rapid Response System Governance, and Professionalism and Teamwork.

CONCLUSIONS

We suggest that a curriculum that educates nurses on the specific requirements of assessing, managing and evaluating all aspects of clinical deterioration is now required.

Effectiveness of collaboration between emergency department and intensive care unit teams on mortality rates of patients presenting with critical illness: a quantitative systematic review protocol

REVIEW OBJECTIVE

The objective of this review is to identify the effectiveness of collaboration between emergency department (ED) and intensive care unit teams on mortality rates of critically ill adult patients in the ED.

Factors influencing the activation of the rapid response system for clinically deteriorating patients by frontline ward clinicians: a systematic review

Purpose

To synthesize factors influencing the activation of the rapid response system (RRS) and reasons for suboptimal RRS activation by ward nurses and junior physicians.

Data sources

Nine electronic databases were searched for articles published between January 1995 and January 2016 in addition to a hand-search of reference lists and relevant journals.

Study selection

Published primary studies conducted in adult general ward settings and involved the experiences and views of ward nurses and/or junior physicians in RRS activation were included.

Data extraction

Data on design, methods and key findings were extracted and collated.

Results of data synthesis

Thirty studies were included for the review. The process to RRS activation was influenced by the perceptions and clinical experiences of ward nurses and physicians, and facilitated by tools and technologies, including the sensitivity and specificity of the activation criteria, and monitoring technology. However, the task of enacting the RRS activations was challenged by seeking further justification, deliberating over reactions from the rapid response team and the impact of workload and staffing. Finally, adherence to the traditional model of escalation of care, support from colleagues and hospital leaders, and staff training were organizational factors that influence RRS activation.

Conclusion

This review suggests that the factors influencing RRS activation originated from a combination of socio-cultural, organizational and technical aspects. Institutions that strive for improvements in the existing RRS or are considering to adopt the RRS should consider the complex interactions between people and the elements of technologies, tasks, environment and organization in healthcare settings.

Predicting medical emergency team calls, cardiac arrest calls and re-admission after intensive care discharge: creation of a tool to identify at-risk patients

We aimed to develop a predictive model for intensive care unit (ICU)-discharged patients at risk of post-ICU deterioration. We performed a retrospective, single-centre cohort observational study by linking the hospital admission, patient pathology, ICU, and medical emergency team (MET) databases. All patients discharged from the Alfred Hospital ICU to wards between July 2012 and June 2014 were included. The primary outcome was a composite endpoint of any MET call, cardiac arrest call or ICU re-admission. Multivariable logistic regression analysis was used to identify predictors of outcome and develop a risk-stratification model. Four thousand, six hundred and thirty-two patients were included in the study. Of these, 878 (19%) patients had a MET call, 51 (1.1%) patients had cardiac arrest calls, 304 (6.5%) were re-admitted to ICU during the same hospital stay, and 964 (21%) had MET calls, cardiac arrest calls or ICU re-admission. A discriminatory predictive model was developed (area under the receiver operating characteristic curve 0.72 [95% confidence intervals {CI} 0.70 to 0.73]) which identified the following factors: increasing age (odds ratio [OR] 1.012 [95% CI 1.007 to 1.017] <i>P</i> <0.001), ICU admission with subarachnoid haemorrhage (OR 2.26 [95% CI 1.22 to 4.16] <i>P</i>=0.009), admission to ICU from a ward (OR 1.67 [95% CI 1.31 to 2.13] <i>P</i> <0.001), Acute Physiology and Chronic Health Evaluation (APACHE) III score without the age component (OR 1.005 [95% CI 1.001 to 1.010] <i>P</i>=0.025), tracheostomy on ICU discharge (OR 4.32 [95% CI 2.9 to 6.42] <i>P</i> <0.001) and discharge to cardiothoracic (OR 2.43 [95%CI 1.49 to 3.96] <i>P</i> <0.001) or oncology wards (OR 2.27 [95% CI 1.05 to 4.89] <i>P</i>=0.036). Over the two-year period, 361 patients were identified as having a greater than 50% chance of having post-ICU deterioration. Factors are identifiable to predict patients at risk of post-ICU deterioration. This knowledge could be used to guide patient follow-up after ICU discharge, optimise healthcare resources, and improve patient outcomes and service delivery.

Medical Emergency Team Event Characteristics from an Australian Pediatric Hospital: A Single-Center, Retrospective Study

OBJECTIVES

To describe the characteristics of medical emergency team (MET) events at an Australian pediatric, tertiary-care center in a way that would allow for comparison with other MET systems.

METHODS

A retrospective, single-center, observational study. Consecutive MET events that occurred between January 2013 and July 2014 at Princess Margaret Hospital for Children in Perth, Western Australia, were included.

RESULTS

There were 46 445 hospital admissions during the study period and 197 MET events in children. This gives a rate of 4.2 MET events per 1000 admissions. Out of 197 pediatric MET events analyzed, there were 2 deaths (1.0%) that occurred during the MET events. All 197 patients were actively treated, with none receiving "do not attempt resuscitation" orders. Of pediatric MET events, 24% (48 of 197) were admitted to the PICU, and 75% (149 of 197) stayed in the ward where the call was made.

CONCLUSIONS

In this tertiary-care, pediatric hospital in Australia, the MET event rate and the rate of admission to the PICU because of MET events are lower than those reported for US pediatric hospitals. Despite these differences, Australian data suggest that outcomes are similar to US pediatric hospitals.

Crisis Teams for Obstetric Patients

An obstetric-specific crisis team allows institutions to optimize the care response for patients with emergent maternal or fetal needs. Characteristics of optimal obstetric rapid response teams are team member role designations; streamlined communication; prompt access to resources; ongoing education, rehearsal, and training; and continual team quality analysis. The outcomes must be incorporated into team responses and reinforced in training. Team response provides a key resource to reassure staff, physicians, and patients that prompt crisis care is only a single call away. Data show that team activation is common, improves the care process, and has promise to improve outcomes.

The Afferent Limb of Rapid Response Systems: Continuous Monitoring on General Care Units

The prevention of adverse events continues to be the focus of patient safety work. Although rapid response systems have improved the efferent limb of the patient's rescue, the detection of the patient's deterioration (the afferent limb) has not been solved. This article provides an overview of the complex issues surrounding patient surveillance by addressing the principal considerations of continuous monitoring as they relate to implementation, choice of sensors and physiologic variables, notification, and alarm balancing, as well as future research opportunities.

Relationship between diurnal patterns in Rapid Response Call activation and patient outcome

BACKGROUND

The Rapid Response Call (RRC) is a system designed to escalate care to a specialised team in response to the detection of patient deterioration. To date, there have been few studies which have explored the relationship between time of day of RRC and patient outcome.

OBJECTIVE

To examine the relationship between the time of RRC activations and patient outcome.

METHOD

All adult inpatients with a RRC in non-critical care wards of a metropolitan Australian hospital in 2012 were retrospectively reviewed. RRCs occurring between 18:00-07:59 were defined as 'out of hours'.

RESULTS

There were 892 RRC during the study period. RRCs out of hours were associated with a higher rate of ICU admissions immediately after the RRC (19.4% vs. 12.3%, p<0.001). Patients experiencing an out-of-hours RRC were more likely to have an in-hospital cardiopulmonary arrest (OR=1.7, p<0.04). In-hospital mortality rate was significantly higher for patients with out-of-hours RRCs (35.5% vs. 25.0%, p=0.014). After adjusting for confounders out-of-hours RRC were independently associated with increased need for ICU admissions and in-hospital mortality.

CONCLUSION

The diurnal timing of RRCs appears to have significant implications for patient mortality and morbidity, patient outcomes are worse if RRC occurs out of hours. This finding has implications for staffing and resource allocation.

Comparison of policies for recognising and responding to clinical deterioration across five Victorian health services

Objectives The aim of the present study was to describe and compare organisational guidance documents related to recognising and responding to clinical deterioration across five health services in Victoria, Australia. Methods Guidance documents were obtained from five health services, comprising 13 acute care hospitals, eight subacute care hospitals and approximately 5500 beds. Analysis was guided by a specific policy analysis framework and a priori themes. Results In all, 22 guidance documents and five graphic observation and response charts were reviewed. Variation was observed in terminology, content and recommendations between the health services. Most health services’ definitions of physiological observations fulfilled national standards in terms of minimum parameters and frequency of assessment. All health services had three-tier rapid response systems (RRS) in place at both acute and subacute care sites, consisting of activation criteria and an expected response. RRS activation criteria varied between sites, with all sites requiring modifications to RRS activation criteria to be made by medical staff. All sites had processes for patient and family escalation of care. Conclusions Current guidance documents related to the frequency of observations and escalation of care omit the vital role of nurses in these processes. Inconsistencies between health services may lead to confusion in a mobile workforce and may reduce system dependability. What is known about the topic? Recognising and responding to clinical deterioration is a major patient safety priority. To comply with national standards, health services must have systems in place for recognising and responding to clinical deterioration. What does this paper add? There is some variability in terminology, definitions and specifications of physiological observations and medical emergency team (MET) activation criteria between health services. Although nurses are largely responsible for physiological observations and escalation of care, they have little authority to direct frequency of observations and triggers for care escalation or tailor assessment to individual patient needs. Failure to identify nurses’ role in policy is concerning and contrary to the evidence regarding nurses and MET activations in practice. What are the implications for practitioners? Inconsistencies in recommendations regarding physiological observations and escalation of care criteria may create patient safety issues when students and staff work across organisations or move from one organisation to another. The validity of other parameters, such as appearance, pain, skin colour and cognition, warrant further consideration as early indicators of deterioration that may be used by nurses to identify clinical deterioration earlier. A better understanding of the relationship between the sensitivity, specificity and frequency of monitoring of particular physiological observations and patient outcomes is needed to improve the predictive validity for identification of clinical deterioration.

Effectiveness of collaboration between emergency department and intensive care unit teams on mortality rates of patients presenting with critical illness: a systematic review

BACKGROUND

The increasing volume of adult patients with critical illness entering emergency departments (EDs) burdens the resources of EDs worldwide. This subpopulation faces a high risk of mortality because they require specialized care which many EDs are not yet poised to deliver. An element crucial to delivering care and decreasing the mortality of critically ill patients in the ED is expert collaborative practice across disciplines. Several ED and intensive care unit (ICU) collaborative models exist including: emergency department intensive care units (EDICU) and medical emergency teams (MET).

OBJECTIVES

To evaluate the effectiveness of collaboration between the ED and ICUs on the mortality rates of critically ill adult ED patients.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adult ED patients, 18 years and over, with non-surgical critical illness meeting the criteria for ICU admission.

TYPES OF INTERVENTION(S)

Collaboration between the ED and ICU in the management of critically ill patients in the ED.

TYPES OF STUDIES

Observational and descriptive studies.

TYPE OF OUTCOME

All-cause mortality, including 30-day mortality and in-hospital mortality rates at any time period.

SEARCH STRATEGY

The comprehensive literature search included published and unpublished studies in English from the beginning of each database through November 30, 2016. Databases searched included: PubMed, CINAHL, Embase and Cochrane Central Register of Controlled Trials (CENTRAL). A search for gray literature and electronic hand searching of relevant journals was also performed.

METHODOLOGICAL QUALITY

Studies were assessed for methodological quality by four independent reviewers using standardized appraisal tools from the Joanna Briggs Institute (JBI).

DATA EXTRACTION

Data related to the methods, participants, interventions and findings were extracted using a standardized data extraction tool from JBI.

DATA SYNTHESIS

Statistical pooling into a meta-analysis was not possible due to the clinical and methodological heterogeneity in the interventions and outcome measures of the included studies. Results are presented in a narrative form.

RESULTS

Three collaborative models (EDICU, Direct Provider-Provider Collaboration and MET) were identified across five studies. Findings from these studies showed conflicting results. The reviewers were unable to synthesize the evidence to state conclusively the effectiveness of collaborative models on mortality rates of critically ill patients.

CONCLUSIONS

There is limited and conflicting evidence related to the effectiveness of EDICU collaborative models on the mortality rates of critically ill patients preventing the development of practice recommendations. This review underscores the need for more research into the benefits of collaborative models between the ED and ICU.

Rapid Response Systems Reduce In-Hospital Cardiopulmonary Arrest: A Pilot Study and Motivation for a Nationwide Survey

Background

Early recognition of the signs and symptoms of clinical deterioration could diminish the incidence of cardiopulmonary arrest. The present study investigates outcomes with respect to cardiopulmonary arrest rates in institutions with and without rapid response systems (RRSs) and the current level of cardiopulmonary arrest rate in tertiary hospitals.

Methods

This was a retrospective study based on data from 14 tertiary hospitals. Cardiopulmonary resuscitation (CPR) rate reports were obtained from each hospital to include the number of cardiopulmonary arrest events in adult patients in the general ward, the annual adult admission statistics, and the structure of the RRS if present.

Results

Hospitals with RRSs showed a statistically significant reduction of the CPR rate between 2013 and 2015 (odds ratio [OR], 0.731; 95% confidence interval [CI], 0.577 to 0.927; P = 0.009). Nevertheless, CPR rates of 2013 and 2015 did not change in hospitals without RRS (OR, 0.988; 95% CI, 0.868 to 1.124; P = 0.854). National university-affiliated hospitals showed less cardiopulmonary arrest rate than private university-affiliated in 2015 (1.92 vs. 2.40; OR, 0.800; 95% CI, 0.702 to 0.912; P = 0.001). High-volume hospitals showed lower cardiopulmonary arrest rates compared with medium-volume hospitals in 2013 (1.76 vs. 2.63; OR, 0.667; 95% CI, 0.577 to 0.772; P < 0.001) and in 2015 (1.55 vs. 3.20; OR, 0.485; 95% CI, 0.428 to 0.550; P < 0.001).

Conclusions

RRSs may be a feasible option to reduce the CPR rate. The discrepancy in cardiopulmonary arrest rates suggests further research should include a nationwide survey to tease out factors involved in in-hospital cardiopulmonary arrest and differences in outcomes based on hospital characteristics.

Effectiveness Analysis of a Part-Time Rapid Response System During Operation Versus Nonoperation

OBJECTIVES

To evaluate the effect of a part-time rapid response system on the occurrence rate of cardiopulmonary arrest by comparing the times of rapid response system operation versus nonoperation.

DESIGN

Retrospective cohort study.

SETTING

A 1,360-bed tertiary care hospital.

PATIENTS

Adult patients admitted to the general ward were screened. Data were collected over 36 months from rapid response system implementation (October 2012 to September 2015) and more than 45 months before rapid response system implementation (January 2009 to September 2012).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The rapid response system operates from 7 AM to 10 PM on weekdays and from 7 AM to 12 PM on Saturdays. Primary outcomes were the difference of cardiopulmonary arrest incidence between pre-rapid response system and post-rapid response system periods and whether the rapid response system operating time affects the cardiopulmonary arrest incidence. The overall cardiopulmonary arrest incidence (per 1,000 admissions) was 1.43. Although the number of admissions per month and case-mix index were increased (3,555.18 vs 4,564.72, p < 0.001; 1.09 vs 1.13, p = 0.001, respectively), the cardiopulmonary arrest incidence was significantly decreased after rapid response system (1.60 vs 1.23; p = 0.021), and mortality (%) was unchanged (1.38 vs 1.33; p = 0.322). After rapid response system implementation, the cardiopulmonary arrest incidence significantly decreased by 40% during rapid response system operating times (0.82 vs 0.49/1,000 admissions; p = 0.001) but remained similar during rapid response system nonoperating times (0.77 vs 0.73/1,000 admissions; p = 0.729).

CONCLUSIONS

The implementation of a part-time rapid response system reduced the cardiopulmonary arrest incidence based on the reduction of cardiopulmonary arrest during rapid response system operating times. Further analysis of the cost effectiveness of part-time rapid response system is needed.