Interventions to reduce mortality from in-hospital cardiac arrest: a mixed-methods study

Successfully initiating an escalation of care in acute ward settings-A qualitative observational study

AIMS

To address knowledge gaps by (i) developing a theoretical understanding of escalation and (ii) identifying escalation success factors.

DESIGN

Non-participant observations were used to examine deteriorating patient escalation events.

METHODS

Escalation event data were collected by a researcher who shadowed clinical staff, between February 16th 2021 and March 17th 2022 from two National Health Service Trusts. Events were analysed using Framework Analysis. Escalation tasks were mapped using a Hierarchical Task Analysis diagram and data presented as percentages, frequency and 95% CI.

RESULTS

A total of 38 observation sessions were conducted, totaling 105 h, during which 151 escalation events were captured. Half of these were not early warning score-initiated and resulted from bleeding, infection, or chest pain. Four communication phenotypes were observed in the escalation events. The most common was Outcome Focused Escalation, where the referrer expected specific outcomes like blood cultures or antibiotic prescriptions. Informative Escalations were often used when a triggering patient's condition was of low clinical concern and ranked as the second most frequent escalation communication type. General Concern Escalations occurred when the referrer did not have predetermined expectations. Spontaneous Interaction Escalations were the least frequently observed, occurring opportunistically in communal workspaces.

CONCLUSION

Half of the events were non-triggering escalations and understanding these can inform the design of systems to support staff better to undertake them. Escalation is not homogenous and differing escalation communication phenotypes exist. Informative Escalations represent an organizational requirement to report triggering warning scores and a targeted reduction of these may be organizationally advantageous. Increasing the frequency of Spontaneous Escalations, through hospital designs, may also be beneficial.

IMPACT STATEMENT

Our work highlights that a significant proportion of escalation workload occurs without a triggering early warning score and there is scope to better support these with designed systems. Further examination of reducing Informative and increasing Spontaneous Escalations is also warranted.

PATIENT AND PUBLIC CONTRIBUTION

Extensive PPIE was completed throughout the lifecycle of this study. PPIE members validated the research questions and overarching aims of the overall study. PPIE members contributed to the design of the study reviewed documents and the final data generated.

NURSE-LED proactive rounding and automatic early-warning score systems to prevent resuscitation incidences among Adults in ward-based Hospitalised patients

Objectives

In this study, we investigated the impact of critical care outreach implemented to overcome the problem of rapid response system (RRS) activation. The aim was to evaluate the impact of nurse-led proactive rounding on the rate of adverse events in a hospital setting using an automatic early-warning score system, without a call-activated team.

Methods

This observational study was conducted at a university hospital in Japan. Beginning in September 2019, critical care outreach via nurse-led proactive rounding of the general ward was conducted, using an automatic early-warning score system. We retrospectively assessed the computerised records of all inpatient days (N = 497,284) of adult inpatients admitted to the hospital from September 2017 to 2020. We compared the adverse event occurrences before and after implementation of the critical care outreach program. The main outcome measures were: unexpected death in the general ward, code blue (an in-hospital resuscitation request code directed towards all staff via broadcast) for non-intensive care unit inpatients and unexpected intensive care unit admissions from the general ward. The secondary outcome was the proportion of patients who received respiratory rate measurement.

Results

The incidence rate ratios of the occurrence of unexpected deaths (0.19, 95% confidence interval: 0.04-0.57) and code blue in the general ward (0.15, 95% confidence interval: 0.025-0.50) decreased. There was no change in unexpected intensive care unit admissions from the general ward (1.25, confidence interval: 0.84-1.82). The proportion of patients who received respiratory rate measurement increased (10.2% vs 16.2%).

Conclusion

Our results suggest that in RRSs, drastic control of the failure of the mechanism to activate a response team may produce positive outcomes. Proactive rounding that bypasses the mechanism to activate a response team component of RRSs may relieve ward nurses of activation failure responsibility and help them overcome the hierarchical hospital structure.

Evaluation of NEWS2 response thresholds in a retrospective observational study from a UK acute hospital

OBJECTIVE

Use of National Early Warning Score 2 (NEWS2) has been mandated in adults admitted to acute hospitals in England. Urgent clinical review is recommended at NEWS2 ≥5. This policy is recognised as requiring ongoing evaluation. We assessed NEWS2 acquisition, alerting at key thresholds and patient outcomes, to understand how response recommendations would affect clinical resource allocation.

SETTING

Adult acute hospital in England.

DESIGN

Retrospective observational cohort study.

PARTICIPANTS

100 362 consecutive admissions between November 2018 and July 2019.

OUTCOME

Death or admission to intensive care unit within 24 hours of a score.

METHODS

NEWS2 were assembled as single scores from consecutive 24-hour time frames, (the first NEWS2 termed 'Index-NEWS2'), or as all scores from the admission (termed All-NEWS2). Scores were excluded when a patient was in intensive care, in the presence of a decision not to attempt cardiopulmonary resuscitation, or on day 1 of elective admission.

RESULTS

A mean of 4.5 NEWS2 were acquired per patient per day. The outcome rate following an Index-NEWS2 was 0.22/100 patient-days. The sensitivity of outcome prediction at Index-NEWS2 ≥5=0.46, and number needed to evaluate (NNE)=52. At this threshold, a mean of 37.6 alerts/100 patient-days would be generated, occurring in 12.3% of patients on any single day. Threshold changes to increase sensitivity by 0.1, would result in a twofold increase in alert rate and 1.5-fold increase in NNE. Overall, NEWS2 classification performance was significantly worse on Index-scores than All-scores (c-statistic=0.78 vs 0.85; p<0.001).

CONCLUSIONS

The combination of low event-rate, high alert-rate and low sensitivity, in patients for cardiopulmonary resuscitation, means that at current NEWS2 thresholds, resource demand would be sufficient to meaningfully compete with other pathways to clinical evaluation. In analyses that epitomise in-patient screening, NEWS2 performance suggests a need for re-evaluation of current response recommendations in this population.

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.

The influence of the built environment in enacting a household model of residential aged care for people living with a mental health condition: A qualitative post-occupancy evaluation

This study undertakes a spatial analysis of an Australian aged care setting where residents receive person-centred support in a specially-designed home-like environment. Focus groups were conducted with staff to explore the impact of the built environment in a new residential aged care setting that has implemented a Household Model of care for people living with mental health conditions. Drawing on Actor-Network Theory and proxemics, we mapped how the built environment supports improved behaviours and care practices in four areas: food preparation and dining, sleep and self-care, site layout, and relationships.

Performance of universal early warning scores in different patient subgroups and clinical settings: a systematic review

OBJECTIVE

To assess predictive performance of universal early warning scores (EWS) in disease subgroups and clinical settings.

DESIGN

Systematic review.

DATA SOURCES

Medline, CINAHL, Embase and Cochrane database of systematic reviews from 1997 to 2019.

INCLUSION CRITERIA

Randomised trials and observational studies of internal or external validation of EWS to predict deterioration (mortality, intensive care unit (ICU) transfer and cardiac arrest) in disease subgroups or clinical settings.

RESULTS

We identified 770 studies, of which 103 were included. Study designs and methods were inconsistent, with significant risk of bias (high: n=16 and unclear: n=64 and low risk: n=28). There were only two randomised trials. There was a high degree of heterogeneity in all subgroups and in national early warning score (I2=72%-99%). Predictive accuracy (mean area under the curve; 95% CI) was highest in medical (0.74; 0.74 to 0.75) and surgical (0.77; 0.75 to 0.80) settings and respiratory diseases (0.77; 0.75 to 0.80). Few studies evaluated EWS in specific diseases, for example, cardiology (n=1) and respiratory (n=7). Mortality and ICU transfer were most frequently studied outcomes, and cardiac arrest was least examined (n=8). Integration with electronic health records was uncommon (n=9).

CONCLUSION

Methodology and quality of validation studies of EWS are insufficient to recommend their use in all diseases and all clinical settings despite good performance of EWS in some subgroups. There is urgent need for consistency in methods and study design, following consensus guidelines for predictive risk scores. Further research should consider specific diseases and settings, using electronic health record data, prior to large-scale implementation.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019143141.

Routine critical care step-down programmes: Systematic review and meta-analysis

BACKGROUND

Patients discharged from critical care to general hospital wards are vulnerable to clinical deterioration, critical care readmission, and death. In response, routine critical care stepdown programmes (CCSDPs) have been widely developed, which involve the review of all patients on general wards following discharge from critical care by multidisciplinary Outreach teams with critical care skills.

AIMS AND OBJECTIVES

This review aims to answer the question: do routine CCSDPs reduce readmission and/or mortality among patients discharged from critical care?

DESIGN

Systematic review of quantitative studies and meta-analysis.

METHODS

Six databases were comprehensively searched from inception (CENTRAL, Cochrane Reviews, MEDLINE, Embase, CINAHL and web of Science), alongside grey literature and trial registers. Studies investigating the effect of routine CCSDPs delivered by Outreach nurses on readmission and/or mortality following discharge from adult critical care to general hospital wards were included. Study quality was assessed using the Cochrane ROBINS-I tool.

RESULTS

Eight studies met the inclusion criteria, with data from 6 studies pooled in 3 meta-analyses. Among patients exposed to routine CCSDPs, pooled data estimated a statistically nonsignificant reduction in the risk of readmission to critical care (risk ratio [RR] 0.85; 95% confidence interval [CI] 0.66-1.09; P = .19), a statistically significant increase in the risk of readmission to critical care within 72 hours (RR 1.49; 95% CI 1.05-2.12; P = .03), a statistically non-significant reduction in risk of mortality following critical care discharge (RR 0.90; 95% CI 0.75-1.07; P = .22), and no association with mortality within 14 days of discharge.

CONCLUSION

This review is unable to definitively conclude whether routine CCSDPs reduce critical care readmission or mortality following critical care discharge.

RELEVANCE TO CLINICAL PRACTICE

While the synthesized evidence does not suggest a change in policy and practice are warranted, neither does it support routine CCSDPs in the absence of high-quality evidence.

Type of Track and Trigger system and incidence of in-hospital cardiac arrest: an observational registry-based study

BACKGROUND

Failure to recognise and respond to patient deterioration on hospital wards is a common cause of healthcare-related harm. If patients are not rescued and suffer a cardiac arrest as a result then only around 15% will survive. Track and Trigger systems have been introduced into the NHS to improve both identification and response to such patients. This study examines the association between the type of Track & Trigger System (TTS) (National Early Warning Score (NEWS) versus non-NEWS) and the mode of TTS (paper TTS versus electronic TTS) and incidence of in-hospital ward-based cardiac arrests (IHCA) attended by a resuscitation team.

METHODS

TTS type and mode was retrospectively collected at hospital level from 106 NHS acute hospitals in England between 2009 to 2015 via an organisational survey. Poisson regression and logistic regression models, adjusted for case-mix, temporal trends and seasonality were used to determine the association between TTS and hospital-level ward-based IHCA and survival rates.

RESULTS

The NEWS was introduced in England in 2012 and by 2015, three-fifths of hospitals had adopted it. One fifth of hospitals had instituted an electronic TTS by 2015. Between 2009 and 2015 the incidence of IHCA fell. Introduction or use of NEWS in a hospital was associated with a reduction of 9.4% in the rate of ward-based IHCA compared to non-NEWS systems (incidence rate ratio 0.906, p < 0.001). The use of an electronic TTS was also associated with a reduction of 9.8% in the rate of IHCA compared with paper-based TTS (incidence rate ratio 0.902, p = 0.009). There was no change in hospital survival.

CONCLUSIONS

The introduction of standardised TTS and electronic TTS have the potential to reduce ward-based IHCA. This is likely to be via a range of mechanisms from early intervention to institution of treatment limits. The lack of association with survival may reflect the complexity of response to triggering of the afferent arm of the rapid response system.

National Early Warning Score: A survey of registered nurses' perceptions, experiences and barriers

AIMS & OBJECTIVES

To describe registered nurses' perceptions, experiences and barriers for using the National Early Warning Score in relation to their work experience and medical affiliation.

BACKGROUND

Indications of inconsistencies in adherence to the National Early Warning Score have emerged.

DESIGN

Web-based questionnaire study.

METHODS

The questionnaire was sent to 3,165 registered nurses working in somatic hospitals in the southern part of Sweden. Strengthening the Reporting of Observational Studies in Epidemiology was adhered.

RESULTS

Seventy-one per cent of the 1,044 respondents reported adherence to the National Early Warning Score guidelines recommended frequency of monitoring and 74% to the clinical response scale. The shorter the working experience, the higher the proportion of registered nurses who answered positively to the National Early Warning Score allowing them to better prioritise their care with short nursing experience. When categorising nurses according to their workplace's medical affiliation, adherence to the National Early Warning Score guidelines recommended frequency of monitoring was reported highest in surgery and orthopaedics (66%) and lowest in the cardiac high dependency unit (52%). Corresponding proportions of reported adherence to the clinical response scale were highest in orthopaedics (82%) and lowest in the cardiac high dependency unit (48%). Lack of response from the doctor was reported as one of the main reasons for not adhering to the National Early Warning Score by 50% of the registered nurse.

CONCLUSION

In general, registered nurses perceived the National Early Warning Score as a useful tool, supporting their gut feeling about an unstable patient. Barriers to the National Early Warning Score were found in doctors and the most experienced registered nurses, indicating the need for resources to be focused on the adherence of these members of the healthcare team.

RELEVANCE TO CLINICAL PRACTICE

In general, the registered nurses answered positively to the National Early Warning Score. We found indications that there is a need to focus resources on the adherence of the most experienced registered nurse and the doctors.