Effect of a Rapid Response Team on the Incidence of In-Hospital Mortality

Larger anesthesia practitioner per operating room ratios are needed to prevent unnecessary non-operative time than to mitigate patient risk: A narrative review

When choosing the anesthesia practitioner to operating room (OR) ratio for a hospital, objectives are applied to mitigate patient risk: 1) ensuring sufficient anesthesiologists to meet requirements for presence during critical intraoperative events (e.g., anesthesia induction) and 2) ensuring sufficient numbers to cover emergencies outside the ORs (e.g., emergent reintubation in the post-anesthesia care unit). At a 24-OR suite with each anesthesiologist supervising residents in 2 ORs, because critical events overlapped among ORs, ≥14 anesthesiologists were needed to be present for all critical events on >90% of days. The suitable anesthesia practitioner to OR ratio would be 1.58, where 1.58 = (24 + 14)/24. Our narrative review of 22 studies from 17 distinct hospitals shows that the practitioner to OR ratio needed to reduce non-operative time is reliably even larger. Activities to reduce non-operative times include performing preoperative evaluations, making prompt evidence-based decisions at the OR control desk, giving breaks during cases (e.g., lunch or lactation sessions), and using induction and block rooms in parallel to OR cases. The reviewed articles counted the frequency of these activities, finding them much more common than urgent patient-care events. Our review shows, also, that 1 anesthesiologist per OR, working without assistants, is often more expensive, from a societal perspective, than having a few more anesthesia practitioners (i.e., ratio > 1.00). These results are generalizable among hundreds of hospitals, based on managerial epidemiology studies. The implication of our narrative review is that existing studies have already shown, functionally, that artificial intelligence and monitoring technologies based on increasing the safety of intraoperative care have little to no potential to influence anesthesia or OR productivity. There are, in contrast, opportunities to use sensor data and decision-support to facilitate communication among anesthesiologists outside of ORs to choose optimal task sequences that reduce non-operative times, thereby increasing production and OR efficiency.

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.

Patients Undergoing Elective Inpatient Major Therapeutic Procedures in Florida Had No Significant Change in Hospital Mortality or Mortality-Related Comorbidities Between 2007 and 2019

BACKGROUND

In a recent study, rapid response team implementation at 1 hospital was associated with only a 0.1% reduction in inpatient mortality from 2005 to 2018, characterized in the accompanying editorial as a "tepid" improvement. The editorialist postulated that an increase in the degree of illness of hospitalized patients might have masked a larger reduction that otherwise might have occurred. Impressions of greater patient acuity during the studied period might have been an artifact of efforts to document more comorbidities and complications, possibly facilitated by the change in diagnosis coding from the International Classification of Diseases , Ninth Revision ( ICD-9 ) to the Tenth Revision ( ICD-10 ).

METHODS

We used inpatient data from every nonfederal hospital in Florida from the last quarter of 2007 through 2019. We studied hospitalizations for major therapeutic surgical procedures with lengths of stay ≥2 days. Using logistic regression with clustering by the Clinical Classification Software (CCS) code of the primary surgical procedure, we evaluated the trends for decreased mortality, changes in the prevalence of Medicare Severity Diagnosis Related Groups (MS-DRG) with complications or comorbidities (CC) or major complications or major comorbidities (MCC), and changes in the van Walraven index (vWI), a measure of patient comorbidities associated with increased inpatient mortality. Also incorporated in the modeling was the change from ICD-9 to ICD-10 .

RESULTS

There were 3,151,107 hospitalizations comprising 130 distinct CCS codes and 453 MS-DRG groups among 213 hospitals. Despite a progressive increase of 4.1% per year in the odds of a CC or MCC ( P = .001), there were no significant changes in the marginal estimates of in-house mortality over time (net estimated decrease, 0.036%; 99% confidence interval [CI], -0.168% to 0.097%; P = .49). There was also absence of a significantly greater fraction of discharges with vWI >0 attributable to the year of the study (odds ratio, 1.017 per year; 99% CI, 0.995-1.041). The changes in MS-DRG to those with CC or MCC were not increased significantly from either the ICD-10 coding change or the number of years after the change.

CONCLUSIONS

Consistent with the previous study, there was at most a small decrease in the mortality rate over a 12-year period. We found no reliable evidence that patients undergoing elective inpatient surgical procedures were any sicker in 2019 than in 2007. There were substantively more comorbidities and complications documented over time, but this was unrelated to the change to ICD-10 coding.

Implementing a Rapid Response Team: A Quality Improvement Project in a Low- to Middle-Income Country

BACKGROUND

The benefits of rapid response teams (RRTs) have been controversial with few studies conducted in low- to middle-income countries.

OBJECTIVE

The aim of this study was to investigate the effectiveness of implementing an RRT on 4 patient outcomes.

METHODS

We conducted a quality improvement pre-and-post design using the Plan-Do-Study-Act model in a tertiary hospital in a low- to middle-income country. We collected data before and after implementing the RRT in 4 phases and over 4 years.

RESULTS

Survival to discharge after cardiac arrest was 25.0% per 1000 discharges in 2016 and increased to 50% in 2019, a 50% increase. The rate of activations per 1000 discharges was 20.45% for the code team in 2016 and 33.6% for the RRT team in 2019. Thirty-one patients who arrested were transferred to a critical care unit before implementing the RRT, and 33% of such patients were transferred after. The time it took the code team to arrive at the bedside was 3.1 minutes in 2016 and decreased to 1.7 minutes for the RRT team to arrive in 2019, a 46% decrease.

DISCUSSION AND CLINICAL IMPLICATIONS

Implementing an RTT led by nurses in a low- to middle-income country increased the survival rate of patients who had a cardiac arrest by 50%. The role of nurses in improving patient outcomes and saving lives is substantial and empowers nurses to call for assistance to save patient lives who show early signs of a cardiac arrest. Hospital administrators should continue to use strategies to improve nurses' timely response to the clinical deterioration of patients and to continue to collect data to assess the effect of the RRT over time.

In-hospital cardiac arrest: the state of the art

In-hospital cardiac arrest (IHCA) is associated with a high risk of death, but mortality rates are decreasing. The latest epidemiological and outcome data from several cardiac arrest registries are helping to shape our understanding of IHCA. The introduction of rapid response teams has been associated with a downward trend in hospital mortality. Technology and access to defibrillators continues to progress. The optimal method of airway management during IHCA remains uncertain, but there is a trend for decreasing use of tracheal intubation and increased use of supraglottic airway devices. The first randomised clinical trial of airway management during IHCA is ongoing in the UK. Retrospective and observational studies have shown that several pre-arrest factors are strongly associated with outcome after IHCA, but the risk of bias in such studies makes prognostication of individual cases potentially unreliable. Shared decision making and advanced care planning will increase application of appropriate DNACPR decisions and decrease rates of resuscitation attempts following IHCA.