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Nelson K, Brooks M, Mead-Harvey C, Quill J, Kiley B, Peworski C, Ritchie A, Sen A. Nurse-led medical emergency response reduces code blue team activations in non-hospitalized patients. Resusc Plus 2024; 18:100642. [PMID: 38689849 PMCID: PMC11059126 DOI: 10.1016/j.resplu.2024.100642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/23/2024] [Accepted: 04/06/2024] [Indexed: 05/02/2024] Open
Abstract
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.
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Affiliation(s)
- Kiley Nelson
- Department of Critical Care Medicine, United States
| | | | | | - Janae Quill
- Department of Critical Care Medicine, United States
| | | | | | | | - Ayan Sen
- Department of Critical Care Medicine, United States
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Majeed J, Chawla S, Bondar E, Chimonas S, Martin SC, O'Sullivan M, Jones D. Rapid Response Team Activations in Oncologic Ambulatory Sites: Characteristics, Interventions, and Outcomes. JCO Oncol Pract 2022; 18:e1961-e1970. [PMID: 36306480 PMCID: PMC9750547 DOI: 10.1200/op.22.00436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/14/2022] [Accepted: 09/13/2022] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Patients with cancer are vulnerable to clinical deterioration. Rapid response teams (RRTs) identify and manage patients with acute changes in clinical status. Although RRTs have been well studied in the hospital setting, there are limited data on patients who require support in the ambulatory or outpatient oncologic settings. Describe baseline characteristics, reasons for activations, interventions, and outcomes of ambulatory oncologic patients receiving RRT activation in a tertiary cancer center. METHODS We conducted a retrospective review of adult (age ≥ 18 years) patients requiring RRT activation at multiple ambulatory sites between July 2020 and June 2021. Demographic and clinical data captured include age, sex, race, ethnicity, do not resuscitate status, vital signs, receipt of active cancer treatment within 30 days, and cancer type. Using Kaplan-Meier survival analysis and multivariable Cox proportion hazard ratio regression models, outcomes of 90-day mortality and hospitalization were assessed. RESULTS There were 322 RRT activations among 427,734 visits to 10 ambulatory sites (0.75 RRTs/1,000 visits). The most frequent reasons were syncope (25.2%), fall (24.5%), and adverse reaction to cancer therapy or intravenous contrast (16.5%). One hundred thirty-seven (42.5%) required transfer to an emergency department, of which 81 (59.1%) required hospital admission. At 90 days, 51 (15.8%) had died, with 44 (86.3%) receiving comfort measures. Kaplan-Meier survival analysis and multivariable Cox proportional hazard ratio regression showed that heart rate > 100 at RRT presentation and hospitalization after a RRT event were significantly associated with 90-day mortality. CONCLUSION Although uncommon, patients with cancer undergoing care at ambulatory sites can suffer acute clinical deterioration needing RRT review. The rates of hospitalization and mortality among such patients are high, suggesting the need for improved end-of-life care.
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Affiliation(s)
- Jibran Majeed
- Advanced Practice Provider, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sanjay Chawla
- Critical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ellen Bondar
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Susan Chimonas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Steven C. Martin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Daryl Jones
- University Melbourne, Victoria, Parkville, Australia
- DEPM Monash University, Victoria, Prahran, Australia
- Austin Department of Intensive Care, Victoria, Heidelberg, Australia
- Critical Care Outreach Austin Hospital, Victoria, Heidelberg, Australia
- International Society of Rapid Response Systems, London, United Kingdom
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Zec T, Di Napoli R, Fievez L, Ben Aziz M, Ottaiano A, Vittori A, Perri F, Cascella M. Efficacy and Safety of Tranexamic Acid in Cancer Surgery. An Update of Clinical Findings and Ongoing Research. J Multidiscip Healthc 2022; 15:1427-1444. [PMID: 35818514 PMCID: PMC9270886 DOI: 10.2147/jmdh.s337250] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/22/2021] [Indexed: 11/23/2022] Open
Abstract
In cancer patients undergoing surgery, tumor biology and anticancer treatments can increase the risk of perioperative bleeding and blood transfusions. Notably, blood transfusions can be potentially associated with an increased risk of life-threatening immune responses, acute lung injury, postoperative infections, and thromboembolism. Moreover, the link between perioperative transfusion and increased risk of cancer recurrence cannot be excluded. On the other hand, cancer patients have an increased risk of thromboembolism due to cancer itself and antineoplastic systemic treatments including chemotherapy and anti-angiogenic drugs. In this complex scenario, effective and safe strategies aimed at the prevention of blood transfusions are warranted. This narrative review addresses the efficacy, and the safety of the synthetic antifibrinolytic agent tranexamic acid (TXA) when used perioperatively in cancer surgery. Although in not oncologic surgery the use of TXA has been extensively studied, in the setting of cancer patients requiring surgery, the evidence is scarce. An overview of the ongoing clinical research is also provided.
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Affiliation(s)
- Tamara Zec
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles, Bruxelles, 1000, Belgium
| | - Raffaela Di Napoli
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles, Bruxelles, 1000, Belgium
| | - Lydwine Fievez
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles, Bruxelles, 1000, Belgium
| | - Mohamed Ben Aziz
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles, Bruxelles, 1000, Belgium
| | - Alessandro Ottaiano
- SSD Innovative Therapies for Abdominal Metastases, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, 80100, Italy
| | - Alessandro Vittori
- Department of Anesthesia and Critical Care, ARCO ROMA, Ospedale Pediatrico Bambino Gesù IRCCS, Piazza S. Onofrio 4, Rome, 00165, Italy
| | - Francesco Perri
- Medical and Experimental Head and Neck Oncology Unit, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, 80100, Italy
- Correspondence: Francesco Perri, Email
| | - Marco Cascella
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples, 80100, Italy
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Aoyama T, Tsuneyoshi I, Otake T, Ouchi K, Kawase Y, Arai M, Shibata N, Fujiwara S, Fujitani S. Rapid response system in Japanese outpatient departments based on online registry: Multicentre observational study. Resusc Plus 2021; 5:100065. [PMID: 34223336 PMCID: PMC8244486 DOI: 10.1016/j.resplu.2020.100065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 11/23/2022] Open
Abstract
Aim The rapid response system (RRS) has become well known as a patient safety system to reduce adverse in-patient events, and it is also required to respond to patients in the outpatient department. However, only few studies have reported on the RRS in the outpatient department. We analysed the current status of the RRS in the outpatient department based on a multicentre online registry in Japan. Methods This is a prospective multicentre observational study. Among the cases registered in the RRS online registry from January 2014 to March 2018, cases from the outpatient department, consisting of the general outpatient department, radiation department, dialysis department, endoscope department, rehabilitation department, and the surrounding areas were eligible for this study. Results A total of 6784 cases were registered, and 1022 cases were included. The main reason for activation was altered mental status (39.1%). Incomplete vital sign recording at activation was 67.0%, whereas body temperature (57.0%) and respiratory rate (36.4%) deficits were frequent. The most common intervention during RRS activation was fluid bolus (38.2%) and oxygen supplementation (30.9%). The general outpatient department accounted for nearly half of the activation locations. The 30-day mortality rate for the location was significantly higher in the dialysis department (P < 0.001). Conclusions We have reported the first study of RRSs in outpatient departments at multicentre facilities in Japan. The difference in the mortality rate for the location was clarified. Future tasks will involve clarifying the RRS outcome indicators in the outpatient department and examining the effectiveness thereof.
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Affiliation(s)
- Takeshi Aoyama
- Department of Emergency and Critical Care Medicine, Miyazaki Prefectural Miyazaki Hospital, 5-30 Kitatakamatsu-cyou, Miyazaki City, Miyazaki 880-0017, Japan.,Graduate School of Medicine and Veterinary Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cyou, Miyazaki City, Miyazaki 889-1692, Japan
| | - Isao Tsuneyoshi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake-cyou, Miyazaki City, Miyazaki 889-1692, Japan
| | - Takanao Otake
- Department of Anesthesiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki City, Okayama 710-8602, Japan
| | - Kazuo Ouchi
- Department of Medical Safety Management, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima City, Fukushima 960-1295, Japan
| | - Yuta Kawase
- Department of Internal Medicine, Kyoritsu General Hospital, 4-33 Goban-cyou, Atsuta-ku, Nagoya City, Aichi 456-8611, Japan
| | - Masayasu Arai
- Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku, Sagamihara City, Kanagawa 252-0375, Japan
| | - Naoaki Shibata
- Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama 641-8509, Japan
| | - Shinsuke Fujiwara
- Department of Emergency Medicine, National Hospital Organization Ureshino Medical Center, 4279-3 Shimojuku-hei, Oaza, Ureshino-machi, Ureshino City, Saga 843-0393, Japan
| | - Shigeki Fujitani
- Department of Emergency and Critical Care Medicine, St. Marianna University Hospital, 2-16-1 Sugao, Miyamae-ku, Kawasaki City, Kanagawa 216-8511, Japan
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Ehara J, Hiraoka E, Hsu HC, Yamada T, Homma Y, Fujitani S. 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. Medicine (Baltimore) 2019; 98:e18475. [PMID: 31876731 PMCID: PMC6946364 DOI: 10.1097/md.0000000000018475] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Jun Ehara
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Hsiang-Chin Hsu
- Department of Emergency Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Toru Yamada
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Yosuke Homma
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba
| | - Shigeki Fujitani
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine Hospital, Kanagawa-ken, Japan
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