Diurnal variation in the performance of rapid response systems: the role of critical care services-a review article

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 hospitalized pediatric patients. This is a retrospective cohort study conduct at a tertiary pediatric hospital. Data were extracted from the charts of 846 patients (with one or more MET activations) over a 5-year period. Also can remove hospital names and affiliated institution from the body of the text as readers can find this information in the author list. 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.

Systems-Based Physical Assessments: Earlier Detection of Clinical Deterioration and Reduced Mortality

BACKGROUND

Despite efforts to improve early detection of deterioration in a patient's condition, delays in activating the rapid response team remain common.

OBJECTIVES

To evaluate delays in activating the rapid response team and the occurrence of serious adverse events before and after implementation of a quality improvement initiative aimed at nurses' performing systems-based physical assessments.

METHODS

A retrospective observational cohort design was used to evaluate all patients who had a rapid response team activation during the study period.

RESULTS

A total of 1080 patients were included in the analysis: 536 patients before the quality improvement initiative and 544 patients after the quality improvement initiative. The delay in activating the rapid response team decreased from 11.7 hours in the before group to 9.6 hours in the after group (P < .001). In the after group, fewer patients were transferred to the intensive care unit (36% vs 41%, P = .02) and those who were transferred had 3.58 times greater odds of death than those who stayed at the same level of care. The after group had a 44% reduction in the odds of mortality compared with the before group.

CONCLUSIONS

When nurses focus on conducting a systems-based physical assessment early in their shift, delays in recognizing a patient's deteriorating condition are reduced, fewer patients are admitted to the intensive care unit, and mortality is significantly reduced.

Characteristics and outcomes of medical emergency team calls in a Swiss tertiary centre - a retrospective observational study

AIMS OF THE STUDY

To describe reasons for medical emergency team (MET) activation over time, to analyse outcomes, and to describe the circadian distribution of MET calls and Intensive Care Unit (ICU) admissions following MET activation.

METHODS

Monocentric retrospective observational study of prospectively collected data on all MET calls between 1^st of January 2012 until 31^st of May 2019. We analysed data on baselines, referring wards, and disposition of all MET patients. In addition, we allocated all MET calls to the hourly intervals over the 24-hour cycle of the day in order to identify peak times of team activation.

RESULTS

A total of 4068 calls in 3277 patients (37% female, n = 1210) were analysed. The mean age was 65.9 years (± 15.7). The MET dose (defined as MET calls/1000 hospital admissions) remained relatively stable over the years with a median of 8.0 calls/1000 hospitalisations (interquartile range [IQR] 7.0-10.0). A total of 2526 calls (62%) occurred out of hours (17:00 to 8:00). The hourly rate of MET activations was greatest during the evening shift (33.8% of calls in seven hours), followed by the day shift (35.8% calls in nine hours) and night shift (30.4% in eight hours). Over the years, staff concern was the main reason for a MET call (n = 1192, 34%), followed by low peripheral oxygen saturation (SpO₂) not responding to oxygen therapy (n = 776, 22%). Abnormal respiratory rate was a trigger to call the MET in 44 cases (1.3%), and was not documented prior to 2017. Overall, in-hospital mortality was 22%.

CONCLUSION

While most common reasons for MET calls over the years were staff concern and low SpO₂, abnormal respiratory rate was the least frequent, but increased after the introduction of the quick sequential organ failure assessment (qSOFA) in 2016. Most MET calls occurred out of hours with peak hours during the evening shift, highlighting the importance of resource allocation during this shift when planning to introduce a MET system in a hospital. In-hospital mortality after a MET call was 22%.

Relationship between time of emergency department admission and adherence to the Surviving Sepsis Campaign bundle in patients with septic shock

BACKGROUND

Nighttime hospital admission is often associated with increased mortality risk in various diseases. This study investigated compliance rates with the Surviving Sepsis Campaign (SSC) 3-h bundle for daytime and nighttime emergency department (ED) admissions and the clinical impact of compliance on mortality in patients with septic shock.

METHODS

We conducted an observational study using data from a prospective, multicenter registry for septic shock provided by the Korean Shock Society from 11 institutions from November 2015 to December 2017. The outcome was the compliance rate with the SSC 3-h bundle according to the time of arrival in the ED.

RESULTS

A total of 2049 patients were enrolled. Compared with daytime admission, nighttime admission was associated with higher compliance with the administration of antibiotics within 3 h (adjusted odds ratio (adjOR), 1.326; 95% confidence interval (95% CI), 1.088-1.617, p = 0.005) and with the complete SSC bundle (adjOR, 1.368; 95% CI, 1.115-1.678; p = 0.003), likely to result from the increased volume of all patients and sepsis patients admitted during daytime hours. The hazard ratios of the completion of SSC bundle for 28-day mortality and in-hospital mortality were 0.750 (95% CI 0.590-0.952, p = 0.018) and 0.714 (95% CI 0.564-0.904, p = 0.005), respectively.

CONCLUSION

Septic shock patients admitted to the ED during the daytime exhibited lower sepsis bundle compliance than those admitted at night. Both the higher number of admitted patients and the higher patients to medical staff ratio during daytime may be factors that are responsible for lowering the compliance.

Weekend Mortality in an Italian Hospital: Immediate versus Delayed Bedside Critical Care Treatment

Background: a number of studies highlighted increased mortality associated with hospital admissions during weekends and holidays, the so–call “weekend effect”. In this retrospective study of mortality in an acute care public hospital in Italy between 2009 and 2015, we compared inpatient mortality before and after a major organizational change in 2012. The new model (Model 2) implied that the intensivist was available on call from outside the hospital during nighttime, weekends, and holidays. The previous model (Model 1) ensured the presence of the intensivist coordinating a Medical Emergency Team (MET) inside the hospital 24 h a day, 7 days a week. Methods: life status at discharge after 9298 and 8223 hospital admissions that occurred during two consecutive periods of 1185 days each (organizational Model 1 and 2), respectively, were classified into “discharged alive”, “deceased during nighttime–weekends–holidays” and “deceased during daytime-weekdays”. We estimated Relative Risk Ratios (RRR) for the associations between the organizational model and life status at discharge using multinomial logistic regression models adjusted for demographic and case-mix indicators, and timing of admission (nighttime–weekends–holidays vs. daytime-weekdays). Results: there were 802 and 840 deaths under Models 1 and 2, respectively. Total mortality was higher for hospital admissions under Model 2 compared to Model 1. Model 2 was associated with a significantly higher risk of death during nighttime–weekends–holidays (IRR: 1.38, 95% CI 1.20–1.59) compared to daytime–weekdays (RRR: 1.12, 95% CI 0.97–1.31) (p = 0.04). Respiratory diagnoses, in particular, acute and chronic respiratory failure (ICD 9 codes 510–519) were the leading causes of the mortality excess under Model 2. Conclusions: our data suggest that the immediate availability of an intensivist coordinating a MET 24 h, 7 days a week can result in a better prognosis of in-hospital emergencies compared to delayed consultation.

Characterizing rescue performance in a tertiary care medical center: a systems approach to provide management decision support

Background

Allocation of limited resources to improve quality, patient safety, and outcomes is a decision-making challenge health care leaders face every day. While much valuable health care management research has concentrated on administrative data analysis, this approach often falls short of providing actionable information essential for effective management of specific system implementations and complex systems. This comprehensive performance analysis of a hospital-wide system illustrates application of various analysis approaches to support understanding specific system behaviors and identify leverage points for improvement. The study focuses on performance of a hospital rescue system supporting early recognition and response to patient deterioration, which is essential to reduce preventable inpatient deaths.

Methods

Retrospective analysis of tertiary care hospital inpatient and rescue data was conducted using a systems analysis approach to characterize: patient demographics; rescue activation types and locations; temporal patterns of activation; and associations of patient factors, including complications, with post-rescue care disposition and outcomes.

Results

Increases in bedside consultations (20% per year) were found with increased rescue activations during periods of resource limitations and changes (e.g., shift changes, weekends). Cardiac arrest, respiratory failure, and sepsis complications present the highest risk for rescue and death. Distributions of incidence of rescue and death by day of patient stay may suggest opportunities for earlier recognition.

Conclusions

Specific findings highlight the potential of using rescue-related risk and targeted resource deployment strategies to improve early detection of deterioration. The approach and methods applied can be used by other institutions to understand performance and allow rational incremental improvements to complex care delivery systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06855-w.

[Postoperative remote monitoring]

During the course of surgical interventions, complications mostly occur in the postoperative period. Slight clinical indications can be observed, which precede a significant deterioration of the patient's condition. On the general ward vital parameters, such as heart and breathing frequencies are measured every 4-8 h. Even if the monitoring of critically ill patients is increased to every 2 h and the measurement of vital functions takes 10 min, the patient is only monitored for 120 min in a 24 h period and remains postoperatively on the general ward without monitoring for 22 out of 24 h. New wireless monitoring systems are available to continuously register some vital functions with the aid of wearable sensors. These systems can alert and alarm ward personnel if the patient's condition deteriorates. Although the optimal monitoring system does not yet exist and implementation of these new wireless monitoring systems might involve some risks, these new methods offer a great opportunity to optimize surveillance of postoperative patients on the general ward.

I-PASS Illness Severity Identifies Patients at Risk for Overnight Clinical Deterioration

BACKGROUND

The I-PASS framework is increasingly being adopted for patient handoffs after a recent study reported a decrease in medical errors and preventable adverse events. A key component of the I-PASS handoff included assignment of illness severity.

OBJECTIVE

We evaluated whether illness severity categories can identify patients at higher risk of overnight clinical deterioration as defined by activation of the rapid response team (RRT).

METHODS

The I-PASS handoff documentation created by internal medicine residents and patient charts with overnight RRT activations from April 2016 through March 2017 were reviewed retrospectively. The RRT activations, illness severity categories, vital signs prior to resident handoff, and patient outcomes were evaluated.

RESULTS

Of the 28 235 written patient handoffs reviewed, 1.3% were categorized as star (sickest patients at risk for higher level of care), 18.8% as watcher (unsure of illness trajectory), and 79.9% as stable (improving clinical status). Of the 98 RRT activations meeting the inclusion criteria, 5.1% were labeled as star, 35.7% as watcher, and 59.2% as stable. Patients listed as watcher had an odds ratio of 2.6 (95% confidence interval 1.7-3.9), and patients listed as star had an odds ratio of 5.2 (95% confidence interval 2.1-13.1) of an overnight RRT activation compared with patients listed as stable. The overall in-hospital mortality of patients with an overnight RRT was 29.6%.

CONCLUSIONS

The illness severity component of the I-PASS handoff can identify patients at higher risk of overnight clinical deterioration and has the potential to help the overnight residents prioritize patient care.

Does the Time of Solitary Rapid Response Team Call Affect Patient Outcome?

Objective

The study aimed to evaluate the effect of a single after-hours rapid response team (RRT) calls on patient outcome.

Design

A retrospective cohort study of RRT-call data over a 3-year period.

Setting

A 600-bedded, tertiary referral, public university hospital.

Participants

All adult patients who had a single RRT-call during their hospital stay.

Intervention

None.

Main outcomes measures

The primary outcome was to compare all-cause in-hospital mortality. The secondary outcomes were to study the hourly variation of RRT-calls and the mortality rate.

Results

Of the total 5,108 RRT-calls recorded, 1,916 patients had a single RRT-call. Eight hundred and sixty-one RRT-calls occurred during work-hours (08:00-17:59 hours) and 1,055 during after-hours (18:00-7:59). The all-cause in-hospital mortality was higher (15.07% vs 9.75%, OR 1.64, 95% CI 1.24-2.17, p value 0.001) in patients who had an after-hours RRT-call. This difference remained statistically significant after multivariate regression analysis (OR 1.50, 95% CI 1.11-2.01, p value 0.001). We noted a lower frequency of hourly RRT-calls after-hours but were associated with higher hourly mortality rates. There was no difference in outcomes for patients who were admitted to ICU post-RRT-call.

Conclusion

Patients having an after-hour RRT-call appear to have a higher risk for hospital mortality. No causal mechanism could be identified other than a decrease in hourly RRT usage during after-hours.

How to cite this article

Singh MY, Vegunta R, Karpe K, Rai S. Does the Time of Solitary Rapid Response Team Call Affect Patient Outcome? Indian J Crit Care Med 2020;24(1):38-43.

Effect of an Electronic Medical Record-Based Screening System on a Rapid Response System: 8-Years' Experience of a Single Center Cohort

An electronic medical record (EMR)-based screening system has been developed as a trigger system for a rapid response team (RRT) that traditionally used direct calling. We compared event characteristics, intensive care unit (ICU) admission, and 28-day mortality following RRT activation of the two trigger systems. A total of 10,026 events were classified into four groups according to the activation time (i.e., daytime or on-call time) and the triggering type (i.e., calling or screening). Among surgical patients, the ICU admission was lowest for the on-call screening group (26.2%). Compared to the on-call screening group, the on-call calling group and daytime calling group showed higher ICU admission with an odds ratio (OR) of 2.07 (95% CI 1.50–2.84, p < 0.001) and OR of 2.68 (95% CI 1.91–3.77, p < 0.001), respectively. The 28-day mortality was lowest for the on-call screening group (8.7%). Compared to the on-call screening group, on-call calling (OR 1.88, 95% CI 1.20–2.95, p = 0.006) and daytime calling (OR 1.89, 95% CI 1.17–3.05, p < 0.001) showed higher 28-day mortality. The EMR-based screening system might be useful in detecting at-risk surgical patients, particularly during on-call time. The clinical usefulness of an EMR-based screening system can vary depending on patients’ characteristics.

Performance of the Afferent Limb of Rapid Response Systems in Managing Deteriorating Patients: A Systematic Review

Introduction

The clinical components of the rapid response system (RRS) are the afferent limb, to ensure identification of in-hospital patients who deteriorate and activation of a response, and the efferent limb, to provide the response. This review aims to evaluate the factors that influence the performance of the afferent limb in managing deteriorating ward patients and their effects on patient outcomes.

Methods

A systematic review was performed for the years 1995–2017 by employing five electronic databases. Articles were included assessing the ability of the ward staffs to monitor, recognize, and escalate care to patient deterioration. The findings were summarized using a narrative approach.

Results

Thirty-one studies met the inclusion criteria. The analysis revealed major themes enclosing several factors affecting management of patients having sudden deterioration. The monitoring and recognition process was conditioned by the lack of recording of physiological parameters, the influence of facilitators, including staff education and training, and barriers, including human and environmental factors, and poor compliance with the calling criteria. The escalation of care process highlighted the influence of cultural barriers and personal judgment on RRS activation. Mainly, delayed team calls were factors strongly associated with the increased risk of unplanned admissions to the intensive care unit and length of stay, hospital length of stay and mortality, and 30-day mortality.

Conclusions

A combination of factors affects the timely identification and response to sudden deterioration by general ward staffs, leading to suboptimal care of patients, delayed or failed activation of RRS teams, and increased risks of worsening outcomes. The research efforts and clinical involvement to improve the governance of the factors limiting the performance of the afferent limb may ensure proper management of hospitalized patients showing physiological deterioration.

Do the Care Process and Survival Chances Differ in Patients Arriving to a Level 1 Indian Trauma Center, during-Hours and after-Hours?

Introduction

Trauma systems vary in performance during different time periods and may affect the patient outcomes, especially in resource-limited settings. The present study was undertaken to study the pattern, epidemiological profile, processes of care variations of trauma victims presenting during-hours and after-hours in a level 1 trauma Center of a lower middle-income country.

Methodology

Retrospective analyses of prospectively collected data registry at a single tertiary care center. Data collected from 2013 to 2015 were analyzed. Patients with a history of trauma and admission to the center or death between arrival and admission were included. Isolated limb injury and patients dead on arrival were excluded.

Results

Of 4692, 1789 (38.1%) patients arrived and were admitted during-hours and 2903 (61.9%) after-hours. The overall in-hospital mortality was 14.9% in the cohort. Moreover, it was 16.10% during after-hours in comparison to 13.0% during-hours. The Revised Trauma Score was statistically different during-hours and after-hours suggesting patients with greater physiological derangement after-hours. The Kaplan-Meier survival curves for 7 days were comparable in two groups with the log-rank test of 078. The proportion of initial radiological investigations (chest X-ray, focused assessment sonography in trauma [FAST], and computerized tomography [CT] scans) was ranged from 84.9% for CT scans in the cohort to 99.3% for FAST.

Conclusions

Processes of care do not differ significantly for the patients admitted at a level 1 trauma center irrespective of time of the day. Although survival probability for the initial 7 days of follow-up is comparable between two groups; however, for 30 and 90 days of follow-up they are significantly different between during-hours and after-hours, likely due to injury severity.

Physical deterioration in an acute mental health unit: A quantitative retrospective analysis of medical emergencies

Nursing management of physical deterioration of patients within acute mental health settings is observed, recorded, and actively managed with the use of standardized Adult Deterioration Detection System (ADDS) charts. Patient deterioration may require the urgent assistance of a hospital rapid response or Medical Emergency Team. A five-and-a-half-year (2011-2016) audit of hospital-wide Medical Emergency Team attendances was conducted in an acute mental health unit of a single large 250 bed regional hospital in Victoria, Australia. Data were extracted from the hospitals' quality and patient safety program, RISKMan, and entered into a statistical data program for analysis. A total of 140 patient records were analysed, and the 'Worried' category (34%, n = 47) was the principle reason for a Medical Emergency Team call in a mental health ward, followed by hypotension (23%, n = 31) and a low Glasgow Coma Score (16%, n = 22). Upon further investigation of the 'Worried' category, the most common conditions recorded were an altered conscious state (22%, n = 9), low oxygen saturation (20%, n = 8), or chest pain (17%, n = 7). Activation of Medical Emergency Team calls predominantly occurred in the daylight morning hours (6am-12md). When data were compared to the general hospital patients, the context of the physiological deterioration of the mental health patients was strikingly similar. Further research is recommended to ascertain the extent and frequency with which staff working in mental health units are performing vital signs monitoring as an essential component of detection of early signs of physiological deterioration.

The PIEPEAR Workflow: A Critical Care Ultrasound Based 7-Step Approach as a Standard Procedure to Manage Patients with Acute Cardiorespiratory Compromise, with Two Example Cases Presented

Critical care ultrasound (CCUS) has been widely used as a useful tool to assist clinical judgement. The utilization should be integrated into clinical scenario and interact with other tests. No publication has reported this. We present a CCUS based "7-step approach" workflow-the PIEPEAR Workflow-which we had summarized and integrated our experience in CCUS and clinical practice into, and then we present two cases which we have applied the workflow into as examples. Step one is "problems emerged?" classifying the signs of the deterioration into two aspects: acute circulatory compromise and acute respiratory compromise. Step two is "information clear?" quickly summarizing the patient's medical history by three aspects. Step three is "focused exam launched": (1) focused exam of the heart by five views: the assessment includes (1) fast and global assessment of the heart (heart glance) to identify cases that need immediate life-saving intervention and (2) assessing the inferior vena cava, right heart, diastolic and systolic function of left heart, and systematic vascular resistance to clarify the hemodynamics. (2) Lung ultrasound exam is performed to clarify the predominant pattern of the lung. Step four is "pathophysiologic changes reported." The results of the focused ultrasound exam were integrated to conclude the pathophysiologic changes. Step five is "etiology explored" diagnosing the etiology by integrating Step two and Step four and searching for the source of infection, according to the clues extracted from the focused ultrasound exam; additional ultrasound exams or other tests should be applied if needed. Step six is "action" supporting the circulation and respiration sticking to Step four. Treat the etiologies according step five. Step seven is "recheck to adjust." Repeat focused ultrasound and other tests to assess the response to treatment, adjust the treatment if needed, and confirm or correct the final diagnosis. With two cases as examples presented, we insist that applying CCUS with 7-step approach workflow is easy to follow and has theoretical advantages. The coming research on its value is expected.

Prevalence, Risk Factors, and Clinical Consequences of Recurrent Activation of a Rapid Response Team: A Multicenter Observational Study

INTRODUCTION

Rapid response teams (RRTs) are groups of health-care providers, implemented by hospitals to respond to distressed hospitalized patients on the hospital wards. Patients assessed by the RRT for deterioration may be admitted to the intensive care unit (ICU) or may be triaged to remain on the wards, putting them at risk of recurrent deterioration and repeat RRT activation. Previous studies evaluating outcomes of patients with recurrent deterioration and multiple RRT activations have produced conflicting results.

METHODS

We used a prospectively collected multicenter registry from 2 hospitals within a single tertiary-level hospital system between 2012 and 2016. Comparisons were made between patients with a single RRT activation and those with multiple RRT activations over the course of their admission. Primary outcome was in-hospital mortality, which was analyzed using multivariable logistic regression.

RESULTS

A total of 5995 patients who had any RRT activation were analyzed. Of that, 1183 (19.7%) patients had recurrent deterioration and multiple RRT activations during their admission. Risk factors for recurrent deterioration included admission from a home setting (as opposed to a long-term care facility), RRT activation during nighttime hours, and delay (>1 hour) to RRT activation. Recurrent deterioration was associated with increased odds of mortality (adjusted odds ratio [OR]: 1.44 [1.28-1.64], P = <.001). Increasing number of RRT activations were associated with increasing risk of mortality. Patients with recurrent deterioration had prolonged median hospital length of stay (21.0 days vs 12.0 days, P < .001), while patients with only a single activation were more likely to be admitted to the ICU (adjusted OR: 2.30 [1.96-2.70], P < .001).

CONCLUSIONS

Recurrent deteriorations leading to RRT activations among hospitalized patients are associated with increased odds of mortality and prolonged hospital length of stay. This work identifies a group of patients who warrant closer attention to help reduce adverse outcomes.

Inter-shift variation in unscheduled intensive care unit transfers at a children's hospital

BACKGROUND

The early detection of clinical deterioration and the prompt escalation of care is important but may be limited in the general ward, especially at night. Identifying variations between work shifts in the number of unscheduled in-hospital intensive care unit (ICU) transfers and emergency transfers involving life-threatening conditions may help implement targeted interventions to reduce delayed transfers and improve patient safety and outcomes.

METHODS

All unscheduled ICU transfers in a tertiary children's hospital, from January 2013 to December 2016, were reviewed retrospectively. The transfers were categorized into safe transfers and adverse safety events (ASE). The 4 year cumulative numbers for each transfer category in each work shift (day, evening, and night) were assessed for comparison. An ASE was defined as transfer after cardiopulmonary resuscitation or tracheal intubation in the ward, or an unrecognized situation awareness failure event transfer, which was defined as previously reported.

RESULTS

Of 244 unscheduled in-hospital ICU transfers, 167 were safe transfers and 77 were ASE. The number of unscheduled transfers and of ASE was highest during the day shift (n = 133 and 40, respectively) and lowest during the night shift (n = 25 and 12, respectively). In contrast, the proportion of ASE in the unscheduled transfers was higher during the night shift (48%) compared with the day and evening shifts (30% and 31%, respectively).

CONCLUSIONS

The occurrence of unscheduled ICU transfers was disproportionately low during the night shift, whereas the majority of ASE happened during the day shift. Future studies focusing on unravelling the reasons for such variations are warranted.

Impact of nighttime Rapid Response Team activation on outcomes of hospitalized patients with acute deterioration

Background

Rapid Response Teams (RRTs) are groups of healthcare providers that are used by many hospitals to respond to acutely deteriorating patients admitted to the wards. We sought to identify outcomes of patients assessed by RRTs outside standard working hours.

Methods

We used a prospectively collected registry from two hospitals within a single tertiary care-level hospital system between May 1, 2012, and May 31, 2016. Patient information, outcomes, and RRT activation information were stored in the hospital data warehouse. Comparisons were made between RRT activation during daytime hours (0800–1659) and nighttime hours (1700–0759). The primary outcome was in-hospital mortality, analyzed using a multivariable logistic regression model.

Results

A total of 6023 RRT activations on discrete patients were analyzed, 3367 (55.9%) of which occurred during nighttime hours. Nighttime RRT activation was associated with increased odds of mortality, as compared with daytime RRT activation (adjusted OR 1.34, 95% CI 1.26–1.40, P = 0.02). The time periods associated with the highest odds of mortality were 0600–0700 (adjusted OR 1.30, 95% CI 1.09–1.61) and 2300–2400 (adjusted OR 1.34, 95% CI 1.01–1.56). Daytime RRT activation was associated with increased odds of intensive care unit admission (adjusted OR 1.40, 95% CI 1.31–1.50, P = 0.02). Time from onset of concerning symptoms to RRT activation was shorter among patients assessed during daytime hours (P < 0.001).

Conclusions

Acutely deteriorating ward patients assessed by an RRT at nighttime had a higher risk of in-hospital mortality. This work identifies important shortcomings in health service provision and quality of care outside daytime hours, highlighting an opportunity for quality improvement.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2005-1) contains supplementary material, which is available to authorized users.

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.

Time of Admission to the PICU and Mortality

OBJECTIVES

To evaluate for any association between time of admission to the PICU and mortality.

DESIGN

Retrospective cohort study of admissions to PICUs in the Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database from 2009 to 2014.

SETTING

One hundred and twenty-nine PICUs in the United States.

PATIENTS

Patients less than 18 years old admitted to participating PICUs; excluding those post cardiac bypass.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 391,779 admissions were included with an observed PICU mortality of 2.31%. Overall mortality was highest for patients admitted from 07:00 to 07:59 (3.32%) and lowest for patients admitted from 14:00 to 14:59 (1.99%). The highest mortality on weekdays occurred for admissions from 08:00 to 08:59 (3.30%) and on weekends for admissions from 09:00 to 09:59 (4.66%). In multivariable regression, admission during the morning 06:00-09:59 and midday 10:00-13:59 were independently associated with PICU death when compared with the afternoon time period 14:00-17:59 (morning odds ratio, 1.15; 95% CI, 1.04-1.26; p = 0.006 and midday odds ratio, 1.09; 95% CI; 1.01-1.18; p = 0.03). When separated into weekday versus weekend admissions, only morning admissions were associated with increased odds of death on weekdays (odds ratio, 1.13; 95% CI, 1.01-1.27; p = 0.03), whereas weekend admissions during the morning (odds ratio, 1.33; 95% CI, 1.14-1.55; p = 0.004), midday (odds ratio, 1.27; 95% CI, 1.11-1.45; p = 0.0006), and afternoon (odds ratio, 1.17; 95% CI, 1.03-1.32; p = 0.01) were associated with increased risk of death when compared with weekday afternoons.

CONCLUSIONS

Admission to the PICU during the morning period from 06:00 to 09:59 on weekdays and admission throughout the day on weekends (06:00-17:59) were independently associated with PICU death as compared to admission during weekday afternoons. Potential contributing factors deserving further study include handoffs of care, rounds, delays related to resource availability, or unrecognized patient deterioration prior to transfer.

Association Between Survival and Time of Day for Rapid Response Team Calls in a National Registry

OBJECTIVES

Decreased staffing at nighttime is associated with worse outcomes in hospitalized patients. Rapid response teams were developed to decrease preventable harm by providing additional critical care resources to patients with clinical deterioration. We sought to determine whether rapid response team call frequency suffers from decreased utilization at night and how this is associated with patient outcomes.

DESIGN

Retrospective analysis of a prospectively collected registry database.

SETTING

National registry database of inpatient rapid response team calls.

PATIENTS

Index rapid response team calls occurring on the general wards in the American Heart Association Get With The Guidelines-Medical Emergency Team database between 2005 and 2015 were analyzed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was inhospital mortality. Patient and event characteristics between the hours with the highest and lowest mortality were compared, and multivariable models adjusting for patient characteristics were fit. A total of 282,710 rapid response team calls from 274 hospitals were included. The lowest frequency of calls occurred in the consecutive 1 AM to 6:59 AM period, with 266 of 274 (97%) hospitals having lower than expected call volumes during those hours. Mortality was highest during the 7 AM hour and lowest during the noon hour (18.8% vs 13.8%; adjusted odds ratio, 1.41 [1.31-1.52]; p < 0.001). Compared with calls at the noon hour, those during the 7 AM hour had more deranged vital signs, were more likely to have a respiratory trigger, and were more likely to have greater than two simultaneous triggers.

CONCLUSIONS

Rapid response team activation is less frequent during the early morning and is followed by a spike in mortality in the 7 AM hour. These findings suggest that failure to rescue deteriorating patients is more common overnight. Strategies aimed at improving rapid response team utilization during these vulnerable hours may improve patient outcomes.

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.