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Dwyer T, Flenady T, Signal T, Boyle CM, Connor J, Le Lagadec D, Goodwin B, Browne M. A theoretical framework for identifying sociocultural factors that influence nurses' compliance with early warning systems for acute clinical deterioration: A cross-sectional survey. Int J Nurs Stud 2024; 158:104846. [PMID: 39043112 DOI: 10.1016/j.ijnurstu.2024.104846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 06/06/2024] [Accepted: 06/20/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Systematic adoption of early warning systems in healthcare settings is dependent on the optimal and reliable application by the user. Psychosocial issues and hospital culture influence clinicians' patient safety behaviours. OBJECTIVE (i) To examine the sociocultural factors that influence nurses' EWS compliance behaviours, using a theory driven behavioural model and (ii) to propose a conceptual model of sociocultural factors for EWS compliance behaviour. DESIGN A cross-sectional survey. SETTING Nurses employed in public hospitals across Queensland, Australia. PARTICIPANTS Using convenience and snowball sampling techniques eligible nurses accessed a dedicated web site and survey containing closed and open-ended questions. 291 nurses from 60 hospitals completed the survey. METHODS Quantitative data were analysed using ANOVA or t-tests to test differences in means. A series of path models based on the theory were conducted to develop a new model. Directed or theory driven content analysis informed qualitative data analysis. RESULTS Nurses report high levels of previous compliance behaviour and strong intentions to continue complying in the future (M=4.7; SD 0.48). Individual compliance attitudes (β 0.29, p<.05), perceived value of escalation (β 0.24, p<.05) and perceived ease or difficulty complying with documentation (β -0.31, p<.05) were statistically significant, predicting 24% of variation in compliance behaviour. Positive personal charting beliefs (β 0.14, p<.05) and subjective norms both explain higher behavioural intent indirectly through personal attitudes. High ratings of peer charting beliefs indirectly explain attitudes through subjective norms (β 0.20, p<.05). Perceptions of control over one's clinical actions (β -0.24, p<.05) and early warning system training (β -0.17, p<.05) directly contributed to fewer difficulties complying with documentation requirements. Prior difficulties when escalating care (β -0.31, p<.05) directly influenced the perceived value of escalating. CONCLUSIONS The developed theory-based conceptual model identified sociocultural variables that inform compliance behaviour (documenting and escalation protocols). The model highlights areas of clinical judgement, education, interprofessional trust, workplace norms and cultural factors that directly or indirectly influence nurses' intention to comply with EWS protocols. Extending our understanding of the sociocultural and system wide factors that hamper nurses' use of EWSs and professional accountability has the potential to improve the compliance behaviour of staff and subsequently enhance the safety climate attitudes of hospitals. TWEETABLE ABSTRACT A newly developed model reports nurse's personal attitudes, peer influence, perceived difficulties encountered documenting and escalation beliefs all predict early warning system compliance behaviour.
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Affiliation(s)
- Trudy Dwyer
- Appleton Institute, CQUniversity Australia, Australia; School of Nursing, Midwifery & Social Studies, CQUniversity Australia, Australia.
| | - Tracy Flenady
- School of Nursing, Midwifery & Social Studies, CQUniversity Australia, Australia.
| | - Tania Signal
- Appleton Institute, CQUniversity Australia, Australia; School of Health, Medical & Applied Sciences, CQUniversity Australia, Australia.
| | | | - Justine Connor
- School of Nursing, Midwifery & Social Studies, CQUniversity Australia, Australia
| | - Danielle Le Lagadec
- School of Nursing, Midwifery & Social Studies, CQUniversity Australia, Australia
| | - Belinda Goodwin
- Centre for Health Research, University of Southern Queensland, Australia
| | - Matthew Browne
- School of Health, Medical & Applied Sciences, CQUniversity Australia, Australia
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Birch A, Varty M. Educational Interventions for Rapid Response Team Members: A Narrative Literature Review. Dimens Crit Care Nurs 2024; 43:266-271. [PMID: 39074232 DOI: 10.1097/dcc.0000000000000655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Research continues to be conducted on rapid response systems as patient outcomes associated with rapid response team activations are still not consistently showing benefit. One particular area of focus that is a growing area is the literature regarding training and education for individual team members of the rapid response team. OBJECTIVE The purpose of this narrative review was to describe the current literature regarding educational interventions for rapid response team members. METHODS This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. To be included in the narrative review, studies needed to be reporting on educational interventional research for rapid response team members of the efferent limb. No studies were excluded based upon study design or publication years. RESULTS This narrative review included 6 studies. Four studies assessed outcomes associated with rapid response team members, and 2 of the studies assessed patient outcomes associated with implementing education routinely for rapid response teams. All studies found a positive impact of implementing educational interventions. DISCUSSION Our narrative review found that limited research has been conducted in the area of educational interventions for rapid response team members, and of the articles identified, most did not assess patient-associated outcomes. The findings demonstrate that this area of research is in its early stages, and further work is needed to identify what content should be provided in the education and what educational methodologies should be employed, and to continue to assess patient health outcomes associated with educational interventions for rapid response team members.
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Maughan NM, Zoberi JE, Garcia-Ramirez JL, Michalski JM, Baumann BC, Amurao M, Luechtefeld D, Marko A, Nestel A, Kim H. Handling Patient Emergencies During Radiopharmaceutical Therapy. Pract Radiat Oncol 2024; 14:457-463. [PMID: 38354977 DOI: 10.1016/j.prro.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 02/16/2024]
Abstract
PURPOSE Radiopharmaceutical therapy (RPT) is a rapidly growing treatment modality. Though uncommon, patients may experience complications during their RPT treatment, which may trigger a rapid response from the hospital team. However, members of this team are typically not familiar with precautions for radiation safety. During these events, it is important to prioritize the patient's health over all else. There are some practices that can help minimize the risk of radiation contamination spread and exposure to staff while tending to the patient. METHODS AND MATERIALS We formed a team to develop a standard protocol for handling patient emergencies during RPT treatment. This team consisted of an authorized user, radiation safety officer, medical physicist, nurse, RPT administration staff, and a quality/safety coordinator. The focus for developing this standardized protocol for RPT patient emergencies was 3-fold: (1) stabilize the patient; (2) reduce radiation exposure to staff; and (3) limit the spread of radiation contamination. RESULTS We modified our hospital's existing rapid response protocol to account for the additional staff and tasks needed to accomplish all 3 of these goals. Each team member was assigned specific responsibilities, which include serving as a gatekeeper to restrict traffic, managing the crash cart, performing chest compressions, timing chest compressions, documenting the situation, and monitoring/managing radiation safety in the area. We developed a small, easy-to-read card for rapid response staff to read while they are en route to the area so they can be aware of and prepare for the unique circumstances that RPT treatments present. CONCLUSIONS Though rapid response events with RPT patients are uncommon, it is important to have a standardized protocol for how to handle these situations beforehand rather than improvise in the moment. We have provided an example of how our team adapted our hospital's current rapid response protocol to accommodate RPT patients.
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Affiliation(s)
- Nichole M Maughan
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri; Department of Radiation Oncology, Intermountain Health, Provo, Utah.
| | - Jacqueline E Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jose L Garcia-Ramirez
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Maxwell Amurao
- Division of Radiation Safety, Department of Environmental Health and Safety, Washington University School of Medicine, St Louis, Missouri
| | - David Luechtefeld
- Division of Radiation Safety, Department of Environmental Health and Safety, Washington University School of Medicine, St Louis, Missouri
| | - Areti Marko
- Department of Radiation Oncology, Barnes Jewish Hospital, St Louis, Missouri
| | - Angela Nestel
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
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Saugel B, Fletcher N, Gan TJ, Grocott MPW, Myles PS, Sessler DI. PeriOperative Quality Initiative (POQI) international consensus statement on perioperative arterial pressure management. Br J Anaesth 2024; 133:264-276. [PMID: 38839472 PMCID: PMC11282474 DOI: 10.1016/j.bja.2024.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/09/2024] [Accepted: 04/05/2024] [Indexed: 06/07/2024] Open
Abstract
Arterial pressure monitoring and management are mainstays of haemodynamic therapy in patients having surgery. This article presents updated consensus statements and recommendations on perioperative arterial pressure management developed during the 11th POQI PeriOperative Quality Initiative (POQI) consensus conference held in London, UK, on June 4-6, 2023, which included a diverse group of international experts. Based on a modified Delphi approach, we recommend keeping intraoperative mean arterial pressure ≥60 mm Hg in at-risk patients. We further recommend increasing mean arterial pressure targets when venous or compartment pressures are elevated and treating hypotension based on presumed underlying causes. When intraoperative hypertension is treated, we recommend doing so carefully to avoid hypotension. Clinicians should consider continuous intraoperative arterial pressure monitoring as it can help reduce the severity and duration of hypotension compared to intermittent arterial pressure monitoring. Postoperative hypotension is often unrecognised and might be more important than intraoperative hypotension because it is often prolonged and untreated. Future research should focus on identifying patient-specific and organ-specific hypotension harm thresholds and optimal treatment strategies for intraoperative hypotension including choice of vasopressors. Research is also needed to guide monitoring and management strategies for recognising, preventing, and treating postoperative hypotension.
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, UK
| | - Tong J Gan
- Division of Anesthesiology and Perioperative Medicine, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
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Mkumbo EG, Willows TM, Odongo Onyango O, Khalid K, Maiba J, Schell CO, Oliwa J, McKnight J, Baker T. Health care workers' experiences of calling-for-help when taking care of critically ill patients in hospitals in Tanzania and Kenya. BMC Health Serv Res 2024; 24:821. [PMID: 39014444 PMCID: PMC11253331 DOI: 10.1186/s12913-024-11254-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/26/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND When caring for critically ill patients, health workers often need to 'call-for-help' to get assistance from colleagues in the hospital. Systems are required to facilitate calling-for-help and enable the timely provision of care for critically ill patients. Evidence around calling-for-help systems is mostly from high income countries and the state of calling-for-help in hospitals in Tanzania and Kenya has not been formally studied. This study aims to describe health workers' experiences about calling-for-help when taking care of critically ill patients in hospitals in Tanzania and Kenya. METHODS Ten hospitals across Kenya and Tanzania were visited and in-depth interviews conducted with 30 health workers who had experience of caring for critically ill patients. The interviews were transcribed, translated and the data thematically analyzed. RESULTS The study identified three thematic areas concerning the systems for calling-for-help when taking care of critically ill patients: 1) Calling-for-help structures: there is lack of functioning structures for calling-for-help; 2) Calling-for-help processes: the calling-for-help processes are innovative and improvised; and 3) Calling-for-help outcomes: the help that is provided is not as requested. CONCLUSION Calling-for-help when taking care of a critically ill patient is a necessary life-saving part of care, but health workers in Tanzanian and Kenyan hospitals experience a range of significant challenges. Hospitals lack functioning structures, processes for calling-for-help are improvised and help that is provided is not as requested. These challenges likely cause delays and decrease the quality of care, potentially resulting in unnecessary mortality and morbidity.
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Affiliation(s)
- Elibariki Godfrey Mkumbo
- The Health Systems, Impact Evaluation and Policy Department, Ifakara Health Institute, Dar Es Salaam, Tanzania.
| | - Tamara Mulenga Willows
- Health Systems Collaborative, University of Oxford/ Wolfson Institute of Population Health, Queen Mary's University London, London, UK
| | | | - Karima Khalid
- The Health Systems, Impact Evaluation and Policy Department, Ifakara Health Institute, Dar Es Salaam, Tanzania
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - John Maiba
- The Health Systems, Impact Evaluation and Policy Department, Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Medicine, Nyköping Hospital, Nyköping, Sweden
| | - Jacquie Oliwa
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacob McKnight
- Health Systems Collaborative, University of Oxford, Oxford, UK
| | - Tim Baker
- The Health Systems, Impact Evaluation and Policy Department, Ifakara Health Institute, Dar Es Salaam, Tanzania
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Patrician PA, Campbell CM, Javed M, Williams KM, Foots L, Hamilton WM, House S, Swiger PA. Quality and Safety in Nursing: Recommendations From a Systematic Review. J Healthc Qual 2024; 46:203-219. [PMID: 38717788 PMCID: PMC11198958 DOI: 10.1097/jhq.0000000000000430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
ABSTRACT As a consistent 24-hour presence in hospitals, nurses play a pivotal role in ensuring the quality and safety (Q&S) of patient care. However, a comprehensive review of evidence-based recommendations to guide nursing interventions that enhance the Q&S of patient care is lacking. Therefore, the purpose of our systematic review was to create evidence-based recommendations for the Q&S component of a nursing professional practice model for military hospitals. To accomplish this, a triservice military nursing team used Covidence software to conduct a systematic review of the literature across five databases. Two hundred forty-nine articles met inclusion criteria. From these articles, we created 94 recommendations for practice and identified eight focus areas from the literature: (1) communication; (2) adverse events; (3) leadership; (4) patient experience; (5) quality improvement; (6) safety culture/committees; (7) staffing/workload/work environment; and (8) technology/electronic health record. These findings provide suggestions for implementing Q&S practices that could be adapted to many healthcare delivery systems.
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Winters BD. Rapid Response Systems. Crit Care Clin 2024; 40:583-598. [PMID: 38796229 DOI: 10.1016/j.ccc.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
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.
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Affiliation(s)
- Bradford D Winters
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 9127 Zayed 1800 Orealns Street, Baltimore, MD 21287, USA.
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8
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Sutton E, Ibrahim M, Plath W, Booth L, Sujan M, McCulloch P, Mackintosh N. Understanding the enablers and barriers to implementing a patient-led escalation system: a qualitative study. BMJ Qual Saf 2024:bmjqs-2024-017132. [PMID: 38902021 DOI: 10.1136/bmjqs-2024-017132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/05/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration but effective contribution to escalation of care can be practically difficult to achieve. This paper reports the enablers and barriers to the implementation of patient-led escalation systems found during a process evaluation of a quality improvement programme Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND). METHODS The research used ethnographic methods, including over 100 hours of observations on surgical units in three English hospitals in order to understand the everyday context of care. Observations focused on the coordination of activities such as handovers and how rescue featured as part of this. We also conducted 27 interviews with a range of clinical and managerial staff and patients. We employed a thematic analysis approach, combined with a theoretically focused implementation coding framework, based on Normalisation Process Theory. RESULTS We found that organisational infrastructural support in the form of a leadership support and clinical care outreach teams with capacity were enablers in implementing the patient-led escalation system. Barriers to implementation included making changes to professional practice without discussing the value and legitimacy of operationalising patient concerns, and ensuring equity of use. We found that organisational work is needed to overcome patient fears about disrupting social and cultural norms. CONCLUSIONS This paper reveals the need for infrastructural support to facilitate the implementation of a patient-led escalation system, and leadership support to normalise the everyday process of involving patients and families in escalation. This type of system may not achieve its goals without properly understanding and addressing the concerns of both nurses and patients.
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Affiliation(s)
| | - Mudathir Ibrahim
- Department of General Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - William Plath
- Nuffield Department of Surgery, Oxford University, Oxford, UK
| | | | - Mark Sujan
- Human Factors Everywhere, Woking, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter McCulloch
- Nuffield Department of Surgery, Oxford University, Oxford, UK
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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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10
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Lucey K, Jones RC, Watson JA, Malakooti M, Stephen RJ. Risk Factors for Deterioration Events in the Pediatric Acute Care Setting. Hosp Pediatr 2024; 14:e260-e266. [PMID: 38784994 DOI: 10.1542/hpeds.2023-007426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 01/23/2024] [Accepted: 01/28/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Rapid response system (RRS) activations resulting in emergency transfers (ETs) and codes outside the ICU are associated with increased mortality and length of stay. We aimed to evaluate the patient and care team characteristics of RRS activations resulting in ETs and codes outside the ICU (together classified as "deterioration events") versus those that did not result in a deterioration event. METHODS For each RRS activation at our institution from 2019 to 2021, data were gathered on patient demographics and medical diagnoses, care team and treatment factors, and ICU transfer. Descriptive statistics, bivariate analyses, and multivariable logistic regression using a backward elimination model selection method were performed to assess potential risk factors for deterioration events. RESULTS Over the 3-year period, 1765 RRS activations were identified. Fifty-three (3%) activations were deemed acute care codes, 64 (4%) were noncode ETs, 921 (52%) resulted in nonemergent transfers to an ICU, and 727 (41%) patients remained in an acute care unit. In a multivariable model, any complex chronic condition (adjusted odds ratio, 6.26; 95% confidence interval, 2.83-16.60) and hematology/oncology service (adjusted odds ratio, 2.19; 95% confidence interval, 1.28-3.74) were independent risk factors for a deterioration event. CONCLUSIONS Patients with medical complexity and patients on the hematology/oncology service had a higher risk of deterioration events than other patients with RRS activations. Further analyzing how our hospital evaluates and treats these specific patient populations is critical as we develop targeted interventions to reduce deterioration events.
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Affiliation(s)
- Kate Lucey
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Hospital Based Medicine
- Center for Quality and Safety
| | | | - J Andrew Watson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Hospital Based Medicine
| | - Marcelo Malakooti
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Rebecca J Stephen
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Hospital Based Medicine
- Center for Quality and Safety
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Dünser MW, Noitz M, Tschoellitsch T, Bruckner M, Brunner M, Eichler B, Erblich R, Kalb S, Knöll M, Szasz J, Behringer W, Meier J. Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission. Wien Klin Wochenschr 2024:10.1007/s00508-024-02374-w. [PMID: 38755419 DOI: 10.1007/s00508-024-02374-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/20/2024] [Indexed: 05/18/2024]
Abstract
Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.
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Affiliation(s)
- Martin W Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria.
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4020, Linz, Austria.
| | - Matthias Noitz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Thomas Tschoellitsch
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Bruckner
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Brunner
- Ambulance and Disaster Relief Services, Oberösterreichisches Rotes Kreuz, 4020, Linz, Austria
| | - Bernhard Eichler
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Romana Erblich
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Stephan Kalb
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Marius Knöll
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | | | - Wilhelm Behringer
- Department of Emergency Medicine, Vienna General Hospital, 1090, Vienna, Austria
| | - Jens Meier
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
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12
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Messmer AS, Baertsch G, Cioccari L. Prevalence and characteristics of medical emergency teams in Switzerland: a nationwide survey of intensive care units. Minerva Anestesiol 2024; 90:409-416. [PMID: 38771165 DOI: 10.23736/s0375-9393.24.17876-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Medical Emergency Teams (METs) have been implemented in many hospitals worldwide and are considered an integral part of the hospital patient safety system. However, data on prevalence, staffing and activation criteria of METs are scarce. Such data are important as they may help to identify areas of quality improvement and barriers to implementation of rapid response systems (RRS). This survey aimed to analyze current characteristics, prevalence, and organization of METs in Switzerland. METHODS We conducted a cross-sectional nationwide online survey, inviting physicians' and nurses' representatives from all registered adult intensive care units (ICU) in Switzerland. RESULTS Of the 74 hospitals invited to participate in the survey, 57 responded (response rate 77%). We obtained 82 individual responses (from 50 physicians and 32 nurses). Twenty-five hospitals (44%) have a MET in place. In most Swiss hospitals, METs are composed of ICU consultants (64%) and ICU nurses (40%) and are activated by phone, with a usual response time of less than 10 minutes. The most common triggers are single abnormal vital signs (80%), while multiple-parameter warning scores are less commonly used (28%). While more than half of the nurses have regular trainings for their MET members (57%), most MET physicians (63%) do not. Systematic data collection of MET calls occurs in only 43% of institutions. Finally, the most common reasons for not having a MET are staff shortage (44%) and lack of funding (19%). CONCLUSIONS Less than 50% of Swiss hospitals with an adult ICU have a MET in place. METs in Switzerland typically include an ICU doctor and an ICU nurse and are available 24/7. Major barriers to MET introduction are staff shortage and lack of funding.
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Affiliation(s)
- Anna S Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland -
| | - Gianna Baertsch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luca Cioccari
- Department of Intensive Care Medicine, Kantonsspital Aarau, Aarau, Switzerland
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Eckert MJ, Varpio L, Soh M, Cristancho S. Qualitative investigation of military surgical resuscitation teams: what are the drivers of success of a rapid response team? BMJ Open 2024; 14:e076000. [PMID: 38521519 DOI: 10.1136/bmjopen-2023-076000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2024] Open
Abstract
OBJECTIVES This qualitative study explores the characteristics of a specialised military medical rapid response team (MRRT), the surgical resuscitation team (SRT). Despite mixed evidence of efficacy, civilian MRRTs are widely employed, with significant variation in structure and function. Recent increased use of these teams to mitigate patient risk in challenging healthcare scenarios, such as global pandemics, mass casualty events and resource-constrained health systems, mandates a reconceptualisation of how civilian MRRTs are created, trained and used. Here, we study the core functions and foundational underpinnings of SRTs and discuss how civilian MRRTs might learn from their military counterparts. DESIGN Semistructured interview-based study using Descriptive Qualitative Research methodology and Thematic Analysis. SETTING Remote audio interviews conducted via Zoom. PARTICIPANTS Participants included 15 members of the United States Special Operations Command SRTs, representing all medical specialties of the SRT as well as operational planners. RESULTS Adaptability was identified as a core function of SRTs and informed by four foundational underpinnings: mission variability, shared values and principles, interpersonal and organisational trust and highly effective teaming. Our findings provide three important insights for civilian MRRTs: (1) team member roles should not be defined by silos of professional specialisation, (2) trust is a key factor in the teaming process and (3) team principles and values result in and are reinforced by organisational trust. CONCLUSION This study offers the first in-depth investigation of a unique military MRRT. Important insights that may offer benefit to civilian MRRT practices include enabling the breakdown of traditional division of labour, allowing for and promoting deep interpersonal and professional familiarity, and facilitating a cycle of positive reinforcement between teams and organisations. Future investigation of small team limitations, comparability to civilian MRRTs, and the team relationship to the larger organisation are needed to better understand how these teams function in a healthcare system and translate to civilian practice.
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Affiliation(s)
- Matthew J Eckert
- Surgery, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
- Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Lara Varpio
- Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael Soh
- Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Snarskis C, Banerjee A, Franklin A, Weavind L. Systems of Care Delivery and Optimization in the Postoperative Care Wards. Anesthesiol Clin 2023; 41:875-886. [PMID: 37838390 DOI: 10.1016/j.anclin.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
A third of all patients are at risk for a serious adverse event, including death, in the first month after undergoing a major surgery. Most of these events will occur within 24 hours of the operation but are unlikely to occur in the operating room or postanesthesia care unit. Most opioid-induced respiratory depression events in the postoperative period resulted in death (55%) or anoxic brain injury (22%). A future state of mature artificial intelligence and machine learning will improve situational awareness of acute clinical deterioration, minimize alert fatigue, and facilitate early intervention to minimize poor outcomes.
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Affiliation(s)
- Connor Snarskis
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arna Banerjee
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Andrew Franklin
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Liza Weavind
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Munroe B, Curtis K, Fry M, Balzer S, Perara P, Couttie T, Royston K, Yu P, Tidswell N, Considine J. Impact of an emergency department rapid response system on inpatient clinical deterioration: A controlled pre-post study. Australas Emerg Care 2023; 26:333-340. [PMID: 37210333 DOI: 10.1016/j.auec.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 05/22/2023]
Abstract
AIM To determine the impact implementation of Emergency Department Clinical Emergency Response System (EDCERS) on inpatient deterioration events and identify contributing causal factors. METHODS EDCERS was implemented in an Australian regional hospital, integrating a single parameter track and trigger criteria for escalation of care, and emergency, specialty and critical care clinician response to patient deterioration. In this controlled pre-post study, electronic medical records of patients who experienced a deterioration event (rapid response call, cardiac arrest or unplanned intensive care admission) on the ward within 72 h of admission from the emergency department (ED) were reviewed. Causal factors contributing to the deteriorating event were assessed using a validated human factors framework. RESULTS Implementation of EDCERS reduced the number of inpatient deterioration events within 72 h of emergency admission with failure or delayed response to ED patient deterioration as a causal factor. There was no change in the overall rate of inpatient deterioration events. CONCLUSION This study supports wider implementation of rapid response systems in the ED to improve management of deteriorating patients. Tailored implementation strategies should be used to achieve successful and sustainable uptake of ED rapid response systems and improve outcomes in deteriorating patients.
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Affiliation(s)
- Belinda Munroe
- Emergency Services, Illawarra Shoalhaven Local Health District, Australia; Faculty of Science, Medicine and Health, University of Wollongong, Australia.
| | - Kate Curtis
- Emergency Services, Illawarra Shoalhaven Local Health District, Australia; Faculty of Science, Medicine and Health, University of Wollongong, Australia; Susan Wakil School of Nursing and Midwifery, University of Sydney, Australia; George Institute for Global Health, Australia
| | - Margaret Fry
- Susan Wakil School of Nursing and Midwifery, University of Sydney, Australia; University of Technology Sydney, Australia; Northern Sydney Local Health District, Australia
| | - Sharyn Balzer
- Emergency Services, Illawarra Shoalhaven Local Health District, Australia; Shoalhaven Hospital Group, Illawarra Shoalhaven Local Health District, Australia
| | - Panchalee Perara
- Wollongong Hospital, Illawarra Shoalhaven Local Health District, Australia
| | - Tracey Couttie
- Division of Child and Families, Illawarra Shoalhaven Local Health District, Australia
| | - Karlie Royston
- Shoalhaven Hospital Group, Illawarra Shoalhaven Local Health District, Australia
| | - Ping Yu
- Centre for Digital Transformation, University of Wollongong, Australia
| | - Natasha Tidswell
- Emergency Services, Illawarra Shoalhaven Local Health District, Australia
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research - Eastern Health, Box Hill, Victoria, Australia
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Piasecki RJ, Himmelfarb CRD, Gleason KT, Justice RM, Hunt EA. The associations between rapid response systems and their components with patient outcomes: A scoping review. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2023; 5:100134. [PMID: 38125770 PMCID: PMC10732356 DOI: 10.1016/j.ijnsa.2023.100134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Background While rapid response systems have been widely implemented, their impact on patient outcomes remains unclear. Further understanding of their components-including medical emergency team triggers, medical emergency team member composition, additional roles in patient care beyond responding to medical emergency team events, and their involvement in "Do-Not-Resuscitate" order placement-may elucidate the relationship between rapid response systems and outcomes. Objective To explore how recent studies have examined rapid response system components in the context of relevant adverse patient outcomes, such as in-hospital cardiac arrests and hospital mortality. Design Scoping review. Methods PubMed, CINAHL, and Embase were searched for articles published between November 2014 and June 2022. Studies mainly focused on rapid response systems and associations with in-hospital cardiac arrests were considered. The following were extracted for analysis: study design, location, sample size, participant characteristics, system characteristics (including medical emergency team member composition, additional system roles outside of medical emergency team events), medical emergency team triggers, in-hospital cardiac arrests, and hospital mortality. Results Thirty-four studies met inclusion criteria. While most studies described triggers used, few analyzed medical emergency team trigger associations with outcomes. Of those, medical emergency team triggers relating to respiratory abnormalities and use of multiple triggers to activate the medical emergency team were associated with adverse patient outcomes. Many studies described medical emergency team member composition, but the way composition was reported varied across studies. Of the seven studies with dedicated medical emergency team members, six found their systems were associated with decreased incidence of in-hospital cardiac arrests. Six of seven studies that described additional medical emergency team roles in educating staff in rapid response system use found their systems were associated with significant decreases in adverse patient outcomes. Four of five studies that described proactive rounding responsibilities reported found their systems were associated with significant decreases in adverse patient outcomes. Reporting of rapid response system involvement in "Do-Not-Resuscitate" order placement was variable across studies. Conclusions Inconsistencies in describing rapid response system components and related data and outcomes highlights how these systems are complex to a degree not fully captured in existing literature. Further large-scale examination of these components across institutions is warranted. Development and use of robust and standardized metrics to track data related to rapid response system components and related outcomes are needed to optimize these systems and improve patient outcomes.
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Affiliation(s)
- Rebecca J. Piasecki
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
| | | | - Kelly T. Gleason
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
| | | | - Elizabeth A. Hunt
- Johns Hopkins University, School of Nursing, Student House 310, 525N. Wolfe St., Baltimore, MD 21205, United States
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Veerappa S, Orosz J, Bailey M, Pilcher D, Jones D. Epidemiology of in-hospital cardiac arrest patients admitted to the intensive care unit in Australia: a retrospective observational study. Intern Med J 2023; 53:2216-2223. [PMID: 36620904 DOI: 10.1111/imj.16007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/29/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND In-hospital cardiac arrest (IHCA) affects approximately 3000 patients annually in Australia. Introduction of the National Standard for Deteriorating Patients in 2011 was associated with reduced IHCA-related intensive care unit (ICU) admissions and reduced in-hospital mortality of such patients. AIMS To assess whether the reduction in IHCA-related ICU admissions from hospital wards seen following the implementation of the national standard (baseline period 2013-2014) was sustained over the follow-up period (2015-2019) in Australia. METHODS A multi-centre retrospective cohort study to compare the characteristics and outcomes of IHCA admitted to the ICU between baseline and follow-up periods. The primary outcome was the proportion of patients admitted to ICU from the ward following IHCA. Secondary outcomes included ICU and hospital mortality of IHCA-related ICU admissions. Data were analysed using hierarchical multivariable logistic regression. RESULTS The proportion of cardiac arrest-related admissions from the ward was lower in the follow-up period when compared to baseline (4.1 vs 3.8%; P = 0.04). Such patients had lower illness severity and were more likely to have limitations of medical treatment at admission. However, after adjustment for severity of illness, the likelihood of being admitted to ICU following cardiac arrest on the ward increased in the follow-up period (odds ratio (OR) 1.13 (1.05-1.22); P = 0.001). Hospital mortality was lower in the follow-up period (50.3 vs 46.3%; P = 0.02), but after adjustment the likelihood of death did not differ between the periods (OR 1.0 (0.86-1.17); P = 0.98). CONCLUSION After adjustment for the severity of illness, the likelihood of being admitted to ICU after IHCA slightly increased in the follow-up period.
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Affiliation(s)
- Shilpa Veerappa
- Intensive Care and Hyperbaric Services, Alfred Health, Melbourne, Victoria, Australia
| | - Judit Orosz
- Intensive Care and Hyperbaric Services, Alfred Health, Melbourne, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resources Evaluation, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Critical Care Network, Safer Care Victoria, Melbourne, Victoria, Australia
- Donate Life in Victoria, Melbourne, Victoria, Australia
| | - Daryl Jones
- Austin Health, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Melbourne, Victoria, Australia
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18
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Hibbert PD, Stewart S, Wiles LK, Braithwaite J, Runciman WB, Thomas MJW. Improving patient safety governance and systems through learning from successes and failures: qualitative surveys and interviews with international experts. Int J Qual Health Care 2023; 35:0. [PMID: 37978851 PMCID: PMC10656601 DOI: 10.1093/intqhc/mzad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 10/04/2023] [Accepted: 10/15/2023] [Indexed: 11/19/2023] Open
Abstract
Patient harm is a leading cause of global disease burden with considerable morbidity, mortality, and economic impacts for individuals, families, and wider society. Large bodies of evidence exist for strategies to improve safety and reduce harm. However, it is not clear which patient safety issues are being addressed globally, and which factors are the most (or least) important contributors to patient safety improvements. We aimed to explore the perspectives of international patient safety experts to identify: (1) the nature and range of patient safety issues being addressed, and (2) aspects of patient safety governance and systems that are perceived to provide value (or not) in improving patient outcomes. English-speaking Fellows and Experts of the International Society for Quality in Healthcare participated in a web-based survey and in-depth semistructured interview, discussing their experience in implementing interventions to improve patient safety. Data collection focused on understanding the elements of patient safety governance that influence outcomes. Demographic survey data were analysed descriptively. Qualitative data were coded, analysed thematically (inductive approach), and mapped deductively to the System-Theoretic Accident Model and Processes framework. Findings are presented as themes and a patient safety governance model. The study was approved by the University of South Australia Human Research Ethics Committee. Twenty-seven experts (59% female) participated. Most hailed from Africa (n = 6, 22%), Australasia, and the Middle East (n = 5, 19% each). The majority were employed in hospital settings (n = 23, 85%), and reported blended experience across healthcare improvement (89%), accreditation (76%), organizational operations (64%), and policy (60%). The number and range of patient safety issues within our sample varied widely with 14 topics being addressed. Thematically, 532 textual segments were grouped into 90 codes (n = 44 barriers, n = 46 facilitators) and used to identify and arrange key patient safety governance actors and factors as a 'system' within the System-Theoretic Accident Model and Processes framework. Four themes for improved patient safety governance were identified: (1) 'safety culture' in healthcare organizations, (2) 'policies and procedures' to investigate, implement, and demonstrate impact from patient safety initiatives, (3) 'supporting staff' to upskill and share learnings, and (4) 'patient engagement, experiences, and expectations'. For sustainable patient safety governance, experts highlighted the importance of safety culture in healthcare organizations, national patient safety policies and regulatory standards, continuing education for staff, and meaningful patient engagement approaches. Our proposed 'patient safety governance model' provides policymakers and researchers with a framework to develop data-driven patient safety policy.
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Affiliation(s)
- Peter D Hibbert
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW 2109, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia
| | - Sasha Stewart
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW 2109, Australia
| | - Louise K Wiles
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW 2109, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW 2109, Australia
| | - William B Runciman
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, GPO Box 2471, Adelaide SA 5001, Australia
| | - Matthew J W Thomas
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, 114-190 Canning Street, Rockhampton, Queensland 4700, Australia
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Tan SC, Hayes L, Cross A, Tacey M, Jones D. Pre-medical emergency team activations - Patient characteristics, outcomes and predictors of deterioration. Aust Crit Care 2023; 36:1078-1083. [PMID: 37076387 DOI: 10.1016/j.aucc.2023.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/31/2023] [Accepted: 03/01/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Pre-medical emergency team (MET) calls are an increasingly common tier of Rapid Response Systems, but the epidemiology of patients who trigger a Pre-MET is not well understoof. OBJECTIVES This study aims to examine the epidemiology and outcomes of patients who trigger a pre-MET activation and identify risk factors for further deterioration. METHODS This is a retrospective cohort study of pre-MET activations in a university-affiliated metropolitan hospital in Australia, between 13 April 2021 and 4 October 2021. A multivariable regression model was used to identify variables associated with further deterioration, defined as a MET call or Code Blue within 24 h of pre-MET activation. RESULTS From a total of 39 664 admissions, there were 7823 pre-MET activations (197.2 per 1000 admissions). Compared to inpatients that did not trigger a pre-MET, the patients were older (68.8 vs 53.8 years, p < 0.001), were more likely to be male (51.0 vs 47.6%, p < 0.001), had an emergency admission (70.1% vs 53.3%, p < 0.001), and were under a medical specialty (63.7 vs 54.9%, p < 0.001). They had a longer hospital length of stay (5.6 vs 0.4 d, p < 0.001) and higher in-hospital mortality (3.4% vs 1.0%, p < 0.001). A pre-MET was more likely to progress to a MET call or Code Blue if it was activated for fever, cardiovascular, neurological, renal, or respiratory criteria (p < 0.001), if the patient was under a paediatric team (p = 0.018), or if there had been a MET call or Code Blue prior to the pre-MET activation (p < 0.001). CONCLUSION Pre-MET activations affect almost 20% of hospital admissions and are associated with a higher risk of mortality. Certain characteristics may predict further deterioration to a MET call or Code Blue, suggesting the potential for early intervention via clinical decision support systems.
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Affiliation(s)
- Sing Chee Tan
- Faculty of Engineering and Information Technology, The University of Melbourne, Parkville, VIC 3010, Australia; Department of Intensive Care, Northern Health, Epping, Victoria, Australia; Division of Digital Health, Northern Health, Epping, Victoria, Australia.
| | - Lachlan Hayes
- Division of Digital Health, Northern Health, Epping, Victoria, Australia
| | - Anthony Cross
- Department of Intensive Care, Northern Health, Epping, Victoria, Australia; Centre for Integrated Critical Care, University of Melbourne, Carlton, Victoria, Australia
| | - Mark Tacey
- Office of Research, Northern Health, Epping, Victoria, Australia; Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Daryl Jones
- Department of Surgery, University of Melbourne, Carlton, Victoria, Australia; Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
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Sprogis SK, Currey J, Jones D, Considine J. Clinicians' use and perceptions of the pre-medical emergency team tier of one rapid response system: A mixed-methods study. Aust Crit Care 2023; 36:1050-1058. [PMID: 36948918 DOI: 10.1016/j.aucc.2023.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/09/2023] [Accepted: 01/22/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND The pre-medical emergency team (pre-MET) tier of rapid response systems facilitates early recognition and treatment of deteriorating ward patients using ward-based clinicians before a MET review is needed. However, there is growing concern that the pre-MET tier is inconsistently used. OBJECTIVE This study aimed to explore clinicians' use of the pre-MET tier. METHODS A sequential mixed-methods design was used. Participants were clinicians (nurses, allied health, doctors) caring for patients on two wards of one Australian hospital. Observations and medical record audits were conducted to identify pre-MET events and examine clinicians' use of the pre-MET tier as per hospital policy. Clinician interviews expanded on understandings gained from observation data. Descriptive and thematic analyses were performed. RESULTS Observations identified 27 pre-MET events for 24 patients that involved 37 clinicians (nurses = 24, speech pathologist = 1, doctors = 12). Nurses initiated assessments or interventions for 92.6% (n = 25/27) of pre-MET events; however, only 51.9% (n = 14/27) of pre-MET events were escalated to doctors. Doctors attended pre-MET reviews for 64.3% (n = 9/14) of escalated pre-MET events. Median time between escalation of care and in-person pre-MET review was 30 min (interquartile range: 8-36). Policy-specified clinical documentation was partially completed for 35.7% (n = 5/14) of escalated pre-MET events. Thirty-two interviews with 29 clinicians (nurses = 18, physiotherapists = 4, doctors = 7) culminated in three themes: Early Deterioration on a Spectrum, A Safety Net, and Demands Versus Resources. CONCLUSIONS There were multiple gaps between pre-MET policy and clinicians' use of the pre-MET tier. To optimise use of the pre-MET tier, pre-MET policy must be critically reviewed and system-based barriers to recognising and responding to pre-MET deterioration addressed.
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Affiliation(s)
- Stephanie K Sprogis
- Deakin University, School of Nursing and Midwifery & Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria, 3220, Australia.
| | - Judy Currey
- Deakin University, School of Nursing and Midwifery & Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria, 3220, Australia.
| | - Daryl Jones
- Department of Intensive Care, Austin Hospital, 145 Studley Rd, Heidelberg, Victoria, 3084, Australia; School of Public Health and Preventive Medicine, Monash University, 533 St Kilda Road, Melbourne, Victoria, 3004, Australia; Department of Surgery, University of Melbourne, Parkville, Victoria, 3010, Australia.
| | - Julie Considine
- Deakin University, School of Nursing and Midwifery & Centre for Quality and Patient Safety in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria, 3220, Australia; Centre for Quality and Patient Safety Research - Eastern Health Partnership, 2/5 Arnold St, Box Hill, Victoria, 3128, Australia.
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Hobohm L, Farmakis IT, Keller K, Scibior B, Mavromanoli AC, Sagoschen I, Münzel T, Ahrens I, Konstantinides S. Pulmonary embolism response team (PERT) implementation and its clinical value across countries: a scoping review and meta-analysis. Clin Res Cardiol 2023; 112:1351-1361. [PMID: 35976429 PMCID: PMC9383680 DOI: 10.1007/s00392-022-02077-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/29/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Over the last years, multidisciplinary pulmonary embolism response teams (PERTs) have emerged to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE). We aimed to systematically investigate the composition and added clinical value of PERTs. METHODS We searched PubMed, CENTRAL and Web of Science until January 2022 for articles designed to describe the structure and function of PERTs. We performed a random-effects meta-analysis of controlled studies (PERT vs. pre-PERT era) to investigate the impact of PERTs on clinical outcomes and advanced therapies use. RESULTS We included 22 original studies and four surveys. Overall, 31.5% of patients with PE were evaluated by PERT referred mostly by emergency departments (59.4%). In 11 single-arm studies (1532 intermediate-risk and high-risk patients evaluated by PERT) mortality rate was 10%, bleeding rate 9% and length of stay 7.3 days [95% confidence interval (CI) 5.7-8.9]. In nine controlled studies there was no difference in mortality [risk ratio (RR) 0.89, 95% CI 0.67-1.19] by comparing pre-PERT with PERT era. When analysing patients with intermediate or high-risk class only, the effect estimate for mortality tended to be lower for patients treated in the PERT era compared to those treated in the pre-PERT era (RR 0.71, 95% CI 0.45-1.12). The use of advanced therapies was higher (RR 2.67, 95% CI 1.29-5.50) and the in-hospital stay shorter (mean difference - 1.6 days) in PERT era compared to pre-PERT era. CONCLUSIONS PERT implementation led to greater use of advanced therapies and shorter in-hospital stay. Our meta-analysis did not show a survival benefit in patients with PE since PERT implementation. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes. REGISTRATION Open Science Framework 10.17605/OSF.IO/SBFK9.
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Affiliation(s)
- Lukas Hobohm
- Department of Cardiology, Center of Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Karsten Keller
- Department of Cardiology, Center of Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Medical Clinic VII, University Hospital Heidelberg, Heidelberg, Germany
| | - Barbara Scibior
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Ingo Sagoschen
- Department of Cardiology, Center of Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Center of Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Academic Teaching Hospital University of Cologne, Cologne, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Thrace, Greece
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Hamlin SK, Fontenot NM, Hooker SJ, Chen HM. Systems-Based Physical Assessments: Earlier Detection of Clinical Deterioration and Reduced Mortality. Am J Crit Care 2023; 32:329-337. [PMID: 37652885 DOI: 10.4037/ajcc2023113] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
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.
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Affiliation(s)
- Shannan K Hamlin
- Shannan K. Hamlin is an associate professor of nursing, Houston Methodist Academic Institute, Houston Methodist Hospital, Houston, Texas
| | - Nicole M Fontenot
- Nicole M. Fontenot is an instructor of nursing, Houston Methodist Academic Institute, Houston Methodist Hospital, Houston, Texas
| | - Steven J Hooker
- Steven J. Hooker is an instructor of nursing, Houston Methodist Academic Institute, Houston Methodist Hospital, Houston, Texas
| | - Hsin-Mei Chen
- Hsin-Mei Chen is an assistant professor, Houston Methodist Academic Institute, Houston Methodist Hospital, Houston, Texas
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Ko JP, Ng LS, Goh KJ, Chai HZ, Phua GC, Tan QL. Staff perception and attitudes towards a medical rapid response team with a multi-tiered response. Singapore Med J 2023; 64:527-533. [PMID: 34911185 PMCID: PMC10476913 DOI: 10.11622/smedj.2021223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 06/14/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Joanna Phone Ko
- Speciality Nursing, Nursing Division, Singapore General Hospital, Singapore
| | - Lit Soo Ng
- Speciality Nursing, Nursing Division, Singapore General Hospital, Singapore
| | - Ken Junyang Goh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Hui Zhong Chai
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Ghee Chee Phua
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Qiao Li Tan
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
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Kritz EM, Thomas JK, Alawa NS, Hadad EB, Guffey DM, Bavare AC. Rapid response events with multiple triggers are associated with poor outcomes in children. Front Pediatr 2023; 11:1208873. [PMID: 37388290 PMCID: PMC10303937 DOI: 10.3389/fped.2023.1208873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/24/2023] [Indexed: 07/01/2023] Open
Abstract
Objective We describe the characteristics and outcomes of pediatric rapid response team (RRT) events within a single institution, categorized by reason for RRT activation (RRT triggers). We hypothesized that events with multiple triggers are associated with worse outcomes. Patients and Methods Retrospective 3-year study at a high-volume tertiary academic pediatric hospital. We included all patients with index RRT events during the study period. Results Association of patient and RRT event characteristics with outcomes including transfers to ICU, need for advanced cardiopulmonary support, ICU and hospital length of stay (LOS), and mortality were studied. We reviewed 2,267 RRT events from 2,088 patients. Most (59%) were males with a median age of 2 years and 57% had complex chronic conditions. RRT triggers were: respiratory (36%) and multiple (35%). Transfer to the ICU occurred after 1,468 events (70%). Median hospital and ICU LOS were 11 and 1 days. Need for advanced cardiopulmonary support was noted in 291 events (14%). Overall mortality was 85 (4.1%), with 61 (2.9%) of patients having cardiopulmonary arrest (CPA). Multiple RRT trigger events were associated with transfer to the ICU (559 events; OR 1.48; p < 0.001), need for advanced cardiopulmonary support (134 events; OR 1.68; p < 0.001), CPA (34 events; OR 2.36; p = 0.001), and longer ICU LOS (2 vs. 1 days; p < 0.001). All categories of triggers have lower odds of need for advanced cardiopulmonary support than multiple triggers (OR 1.73; p < 0.001). Conclusions RRT events with multiple triggers were associated with cardiopulmonary arrest, transfer to ICU, need for cardiopulmonary support, and longer ICU LOS. Knowledge of these associations can guide clinical decisions, care planning, and resource allocation.
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Affiliation(s)
- Erin M. Kritz
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| | - Jenilea K. Thomas
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| | - Nawara S. Alawa
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| | - Elit B. Hadad
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| | - Danielle M. Guffey
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
| | - Aarti C. Bavare
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
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Cresham Fox S, Taylor N, Marufu TC, Hendron E, Manning JC. Paediatric family activated rapid response interventions; qualitative systematic review. Intensive Crit Care Nurs 2023; 75:103363. [PMID: 36473743 DOI: 10.1016/j.iccn.2022.103363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Failure to recognise deterioration early which results in patient death, is considered failure to rescue and it is identified as one of the leading causes of harm to patients. It is recognised that patients and their families can often recognise changes within the child's condition before healthcare professionals. To mitigate the risk of failure to rescue and promote early intervention, family-activated rapid response systems are becoming widely acknowledged and accepted as part of family integrated care. OBJECTIVE To identify current family-activated rapid response interventions in hospitalised paediatric patients and understand mechanisms by which family activation works. METHODS A narrative systematic review of published studies was conducted. Seven online databases; AMED, CINHAL, EMBASE, EMCARE, HMIC, JBI, and Medline were searched for potentially relevant papers. The critical appraisal skills programme tool was used to assess methodological rigor and validity of included studies. RESULTS Six studies met the predefined inclusion criteria. Five telephone family activation interventions were identified; Call for Help, medical emergency-teams, Condition HELP, rapid response teams, and family initiated rapid response. Principles underpinning all interventions were founded on a principal of granting families access to a process to escalate concerns to hospital emergency teams. Identified interventions outcomes and mechanisms include; patient safety, empowerment of families, partnership working/ family centred care, effective communication and better patient outcomes. Interventions lacked multi-lingual options. CONCLUSION Family activation rapid response system are fundamental to family integrated care and enhancing patient safety. Underlying principles and concepts in delivering interventions are transferable across global healthcare system.
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Affiliation(s)
- Shannon Cresham Fox
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Nicola Taylor
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Takawira C Marufu
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Centre for Children and Young People Health Research, School of Health Sciences, Faculty of Medicine and Health Sciences, The University of Nottingham, Nottingham, United Kingdom.
| | - Elizabeth Hendron
- Library Services, Nottingham University Hospitals NHS Trust, City Campus, Nottingham, United Kingdom
| | - Joseph C Manning
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Centre for Children and Young People Health Research, School of Health Sciences, Faculty of Medicine and Health Sciences, The University of Nottingham, Nottingham, United Kingdom
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The patient experience of a medical emergency team review: A convergent mixed-methods study. Aust Crit Care 2023; 36:254-261. [PMID: 35177341 DOI: 10.1016/j.aucc.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/21/2021] [Accepted: 12/21/2021] [Indexed: 11/23/2022] Open
Abstract
AIMS The aim of this study was to explore clinician-patient engagement during, and patient experience of, medical emergency team (MET) reviews. DESIGN This study involved a convergent mixed-methods design. METHODS This three-phase study was conducted at two hospitals of one Australian health service. Reviews by the MET were observed for clinician-patient engagement behaviours; medical records were audited to confirm patient demographics and clinical characteristics; and patients who received a MET review were interviewed. Quantitative data were analysed using descriptive statistics, and thematic analysis of qualitative interview data was conducted. RESULTS In total, 26 MET reviews were observed for 22 patients (median age = 81.5 years and 68.2% females). Between 8 and 13 clinicians and other staff members were present during each review, with a total of 209 clinicians present during the 26 reviews. Clinicians were not observed to speak directly or indirectly to the patient about their care in 38.5% (n = 10/26) of the MET reviews, and 58.3% (n = 56/96) of interventions were performed without explanation. Four themes were identified from the interviews: An unexpected event; A lack of understanding; In good hands, and What happens next? CONCLUSION Clinician-patient engagement was infrequent during and after MET reviews. Patients experienced surprise from the sudden arrival of clinicians in their room and had poor levels of understanding about the review. However, most patients felt supported and safe. MET reviews are frequent safety-critical events, and this study identified the patient experience of these events. Clinicians should be aware that patients expressed they were surprised and shocked by the review and that an explanation of what was being done by the clinical team was rarely offered. These findings can be used to inform strategies to improve their patient-engagement behaviours and patient-centred care.
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Exploration of Ward-Based Nurses' Perspectives on Their Preparedness to Recognize Clinical Deterioration: A Scoping Review. J Patient Saf 2023; 19:99-109. [PMID: 36729628 DOI: 10.1097/pts.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Despite initiatives in the early recognition of clinical deterioration, the incidence of failure to recognize clinical deterioration in patients continues to occur contributing to the ongoing rise of in-hospital mortality and morbidity. OBJECTIVE The aim of the study was to explore and appraise the research evidence that related to ward-based nurses' preparedness to recognize the clinically deteriorating patient. METHODS A scoping review was undertaken as this approach enabled the researchers to investigate the breadth of the available evidence through broad inclusion criteria. A comprehensive database search was conducted through the Cochrane Library; Cumulative Index to Nursing and Allied Health Literature; MEDLINE; ProQuest; PubMed; and Wiley Online Library. Each article was critically appraised and analyzed using a critical appraisal tool and thematic analysis, respectively. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews checklist. RESULTS Twelve primary sources of literature met the eligibility criteria. Through thematic analyses 6 primary themes were identified: implication of experience on preparedness; interprofessional and intraprofessional relationships; knowledge of calling criteria, process and procedures; requirement for a supportive system and culture; existence of hierarchy within healthcare impacting care; and clinical deterioration as an education opportunity. CONCLUSIONS This review identified central issues that impacted on ward-based nurses' preparedness. Further development of collaborative, supportive professional relationships across-and-within disciplines is needed. Effective use of clinical deterioration situations as educational opportunities would also assist nurses' preparedness through skill and knowledge development. However, more research evidence will be needed because of the limited data available on the topic.
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Olsen SL, Nedrebø BS, Strand K, Søreide E, Kvaløy JT, Hansen BS. Reduction in omission events after implementing a Rapid Response System: a mortality review in a department of gastrointestinal surgery. BMC Health Serv Res 2023; 23:179. [PMID: 36810005 PMCID: PMC9945730 DOI: 10.1186/s12913-023-09159-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/07/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Hospitals worldwide have implemented Rapid Response Systems (RRS) to facilitate early recognition and prompt response by trained personnel to deteriorating patients. A key concept of this system is that it should prevent 'events of omission', including failure to monitor patients' vital signs, delayed detection, and treatment of deterioration and delayed transfer to an intensive care unit. Time matters when a patient deteriorates, and several in-hospital challenges may prevent the RRS from functioning adequately. Therefore, we must understand and address barriers for timely and adequate responses in cases of patient deterioration. Thus, this study aimed to investigate whether implementing (2012) and developing (2016) an RRS was associated with an overall temporal improvement and to identify needs for further improvement by studying; patient monitoring, omission event occurrences, documentation of limitation of medical treatment, unexpected death, and in-hospital- and 30-day mortality rates. METHODS We performed an interprofessional mortality review to study the trajectory of the last hospital stay of patients dying in the study wards in three time periods (P1, P2, P3) from 2010 to 2019. We used non-parametric tests to test for differences between the periods. We also studied overall temporal trends in in-hospital- and 30-day mortality rates. RESULTS Fewer patients experienced omission events (P1: 40%, P2: 20%, P3: 11%, P = 0.01). The number of documented complete vital sign sets, median (Q1,Q3) P1: 0 (0,0), P2: 2 (1,2), P3: 4 (3,5), P = 0.01) and intensive care consultations in the wards ( P1: 12%, P2: 30%, P3: 33%, P = 0.007) increased. Limitations of medical treatment were documented earlier (median days from admission were P1: 8, P2: 8, P3: 3, P = 0.01). In-hospital and 30-day mortality rates decreased during this decade (rate ratios 0.95 (95% CI: 0.92-0.98) and 0.97 (95% CI: 0.95-0.99)). CONCLUSION The RRS implementation and development during the last decade was associated with reduced omission events, earlier documentation of limitation of medical treatments, and a temporal reduction in the in-hospital- and 30-day mortality rates in the study wards. The mortality review is a suitable method to evaluate an RRS and provide a foundation for further improvement. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Siri Lerstøl Olsen
- Department of Quality and Health Technology, Faculty of Health Sciences, SHARE-Centre for Resilience in Healthcare, University of Stavanger, Kjell Arholms gate 43, 4036, Stavanger, Norway. .,Department of Emergency Medicine, Stavanger University Hospital, Stavanger, Norway.
| | - Bjørn S Nedrebø
- grid.412008.f0000 0000 9753 1393Department of Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
| | - Kristian Strand
- grid.412835.90000 0004 0627 2891Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Eldar Søreide
- grid.18883.3a0000 0001 2299 9255Faculty of Health Sciences, University of Stavanger, Stavanger, Norway ,grid.412835.90000 0004 0627 2891Section for Quality and Patient Safety, Stavanger University Hospital, Stavanger, Norway
| | - Jan Terje Kvaløy
- grid.18883.3a0000 0001 2299 9255Department of Mathematics and Physics, Faculty of Science and Technology, University of Stavanger, Stavanger, Norway ,grid.412835.90000 0004 0627 2891Research Department, Stavanger University Hospital, Stavanger, Norway
| | - Britt Sætre Hansen
- grid.18883.3a0000 0001 2299 9255Department of Quality and Health Technology, Faculty of Health Sciences, SHARE—Centre for Resilience in Healthcare, University of Stavanger, Kjell Arholms gate 43, 4036 Stavanger, Norway ,grid.412835.90000 0004 0627 2891The Research Group for Nursing and Health Care Science, Stavanger University Hospital, Stavanger, Norway
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Piasecki RJ, Hunt EA, Perrin N, Spaulding EM, Winters B, Samuel L, Davidson PM, Strobos NC, Churpek M, Himmelfarb CR. Using rapid response system trigger clusters to characterize patterns of clinical deterioration among hospitalized adult patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.06.23285560. [PMID: 36798369 PMCID: PMC9934794 DOI: 10.1101/2023.02.06.23285560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Background Many rapid response system (RRS) events are activated using multiple triggers. However, the patterns in which RRS triggers co-occur to activate the medical emergency team (MET) to respond to RRS events is unknown. The purpose of this study was to identify and describe the patterns (RRS trigger clusters) in which RRS triggers co-occur when used to activate the MET and determine the association of these clusters with outcomes using a sample of hospitalized adult patients. Methods RRS events among adult patients from January 2015 to December 2019 in the Get With The Guidelines- Resuscitation registry's MET module were examined (n=134,406). A combination of cluster analyses methods was performed to group patients into RRS trigger clusters based on the triggers used to activate their RRS events. Pearson's chi-squared and ANOVA tests were used to examine differences in patient characteristics across RRS trigger clusters. Multilevel logistic regression was used to examine the associations between RRS trigger clusters and outcomes following RRS events. Results Six RRS trigger clusters were identified in the study sample. The RRS triggers that predominantly identified each cluster were as follows: tachypnea, new onset difficulty in breathing, and decreased oxygen saturation (Cluster 1); tachypnea, decreased oxygen saturation, and staff concern (Cluster 2); respiratory depression, decreased oxygen saturation, and mental status changes (Cluster 3); tachycardia and staff concern (Cluster 4); mental status changes (Cluster 5); hypotension and staff concern (Cluster 6). Significant differences in patient characteristics were observed across RRS trigger clusters. Patients in Clusters 3 and 6 were associated with an increased likelihood of in-hospital cardiac arrest (IHCA [p<0.01]), while Cluster 4 was associated with a decreased likelihood of IHCA (p<0.01). All clusters were associated with an increased risk of mortality (p<0.01). Conclusions We discovered six novel RRS trigger clusters with differing relationships to adverse patient outcomes following RRS events. RRS trigger clusters may prove crucial in clarifying the associations between RRS events and adverse outcomes and may aid in clinician decision-making during RRS events.
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Abstract
OBJECTIVES Rapid response (RR) systems are associated with decreased hospital mortality. Systemic biases and inequities can negatively impact RR outcomes. Language barriers between patients and providers are associated with worse outcomes, but it is unknown if language barriers are associated with RR outcomes. METHODS We analyzed all adult hospitalized patients who experienced a RR over one year (January 2020 to December 2020) at a tertiary care academic medical center. We used an objective scoring system to establish disease severity at the time of the event. We then compared disease severity and outcomes for patients who are primary language Spanish (PLS) and primary language English (PLE) using both univariable and multivariable analyses. RESULTS Of 1133 patients, 42 identified as PLS and 1091 as PLE. In multivariable analyses, PLS patients had significantly higher disease severity scores, as measured by deterioration index score (8.2, p = 0.021) at the time of their rapid responses. PLS patients also had 18.5% increase in length of stay (LOS) after RRs and this disparity was not mitigated when controlling for disease severity at the time of RRs. PLS was not a significant predictor for hospital mortality after RRs. CONCLUSIONS Our study found that PLS patients had increased disease severity at the time of RRs and increased LOS after RRs. However, the disparity in LOS was not mitigated when controlling for disease severity at the time of RRs. These findings suggest that language barriers may cause both delays in activation of RR systems, as well as the care provided during and after RRs.
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Affiliation(s)
- Lauren Raff
- Division of Trauma and Acute Care Surgery, University of North Carolina at Chapel Hill Department of Surgery, Chapel Hill, NC, US
| | - Carlton Moore
- Division of Hospital Medicine, University of North Carolina at Chapel Hill Department of Medicine, Chapel Hill, NC, US
| | - Evan Raff
- Division of Hospital Medicine, University of North Carolina at Chapel Hill Department of Medicine, Chapel Hill, NC, US.,Division of Hospital Medicine, University of North Carolina at Chapel Hill Department of Medicine, 101 Manning Drive, 27599, Chapel Hill, NC, US
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Weatherburn C, Greenwood M. The role of the intensive care nurse in the medical emergency team: A constructivist grounded theory study. Aust Crit Care 2023; 36:119-126. [PMID: 36567209 DOI: 10.1016/j.aucc.2022.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Intensive care nurses are essential members of rapid response systems (RRSs) with little qualitative data available to capture what intensive care nurses do as they navigate their way around the complexity of a medical emergency call. OBJECTIVE The study aims to describe and explain the role of the intensive care nurse within the medical emergency team (MET) of a tertiary-level hospital to develop an understanding of the intensive care nurse role, the way it is enacted, and their responsibilities within the team. METHOD A constructivist grounded theory research approach collected qualitative data from intensive care nurses who had experience attending MET calls. Data were collected through participant observation (16 MET calls), followed by 12 semistructured interviews. FINDINGS A substantive theory was developed that 'keeping patient's safe' is a fundamental role of the intensive care nurse within the MET. This is derived from four key concepts: Systematic framework for decision making, Figuring it out, Directing care, and Patient safety. Each of these concepts was developed from categories that describe the role of the intensive care unit nurse on the MET. They include performing assessments and interventions, figuring it out, critical thinking, prioritising care, directing care, being supportive, and ensuring patient safety. CONCLUSION This study provides new insights into and an understanding of the ways intensive care nurses work within the MET, making a significant contribution to our existing understanding of the role.
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Affiliation(s)
- Cindy Weatherburn
- Department of Critical Care Medicine, Royal Hobart Hospital, GPO BOX 1061, Hobart Tasmania 7001, Australia.
| | - Melanie Greenwood
- School of Nursing, College of Health and Medicine, Private Bag 135, Hobart, Tasmania 7001, Australia.
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Mølgaard RR, Jørgensen L, Grønkjær M, Madsen JØ, Christensen EF, Voldbjerg SL. Nurses' and Physicians' Ideas on Initiatives for Effective Use of the Early Warning Score: A Participatory Study. Glob Qual Nurs Res 2023; 10:23333936231210147. [PMID: 38028737 PMCID: PMC10676632 DOI: 10.1177/23333936231210147] [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: 06/30/2022] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Ineffective use of the early warning score (EWS) can compromise recognition and response to patients' deteriorating condition. This study explores nurses' and physicians' ideas on initiatives for supporting the effective use of the EWS in a hospital setting. Participatory workshops were conducted, and data were analyzed using content analysis. Ideas generated for integrating new functions into the EWS protocol to facilitate effective use are described. Also recommended was that all users receive training and an update on how to use the EWS score to support acceptance and confidence using the protocol and thereby increase adherence to the EWS. Further research is needed on the efficiency of incorporating nurses' clinical judgment in the EWS protocol within different specialties and the effect on adherence to the tool.
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Li W, Yu H, Li B, Zhang Y, Fu M. The transcultural adaptation and validation of the Chinese version of the Attitudes Toward Recognizing Early and Noticeable Deterioration scale. Front Psychol 2022; 13:1062949. [PMID: 36562070 PMCID: PMC9765647 DOI: 10.3389/fpsyg.2022.1062949] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
Background In China, clinical deterioration events present a real problem for every clinical nurse. Patient deterioration is determined in part by nurses' attitudes toward early recognition of clinical deterioration. However, research on attitudes toward the early identification of clinical deterioration is still in its infancy, and even less research has been done on ward nurses' attitudes toward the early identification of clinical deterioration. To drive behavioral change and improve the care of deteriorating patients, nurses need comprehensive, valid, and reliable tools to assess their attitudes toward early identification of deterioration. Objective In this study, we aimed to translate the Attitudes Toward Recognizing Early and Noticeable Deterioration (ATREND) scale into Chinese and to assess its validity and reliability tests. Methods From March 2022 to July 2022, the ATREND scale was translated, back-translated, and cross-culturally adapted into the Chinese version using a modified Brislin translation model. Then, 460 ward nurses were recruited from tertiary Grade A general hospitals in two cities: Shenyang and Jinzhou in Liaoning Province, China. Reliability analyses were conducted using internal consistency, split-half, and test-retest reliability. We convened a committee of experts to determine the validity of the content. Tests of the structural validity of the scale were conducted using exploratory and validation factor analyses. Results The Cronbach's α value of the Chinese version of the ATREND scale was 0.804, and the Cronbach's α value of the dimensions ranged from 0.782 to 0.863. The split-half reliability and test-retest reliability were 0.846 and 0.711, respectively. Furthermore, the scale has an index of content validity of 0.922, indicating a high level of content validity. In exploratory factor analysis, eigenvalues, total variance explained, and scree plot supported a three-factor structure. The three-factor model supported by this study was confirmed by confirmatory factor analysis (CFA). Moreover, the model fitting indexes (e.g., χ 2/DF = 1.498, GFI = 0.954, RMSEA = 0.047) were all within acceptable limits based on the CFA. Conclusion The Chinese version of the scale is reliable and valid among ward nurses. Nursing educators and clinicians will be able to develop targeted educational programs to enhance the competence and behaviors of Chinese ward nurses in recognizing clinical deterioration. It will be based on the developed scale to assess Chinese nurses' attitudes and practices regarding early recognition of clinical deterioration. As a result, it is necessary to consider the Chinese scale's three-factor structure. The developed three-factor structured scale will assess Chinese ward nurses' attitudes and practices toward patient observation and vital sign-monitoring empowerment, enlightening them on the importance of patient observation, encouraging ward nurses to use a wider range of patient assessment techniques to capture early signs of clinical deterioration, and helping ward nurses to develop clinical confidence to monitor clinical deterioration.
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Affiliation(s)
- Wenbo Li
- Department of Nursing, Jinzhou Medical University, Jinzhou, China
| | - Hongyu Yu
- Department of Nursing, Jinzhou Medical University, Jinzhou, China,*Correspondence: Hongyu Yu,
| | - Bing Li
- Department of Dermatology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yanli Zhang
- Department of Nursing, Jinzhou Medical University, Jinzhou, China
| | - Mingshu Fu
- Department of Neurosurgery, The First Affiliated Hospital of China Medical University, Shenyang, China
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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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Sutton E, Booth L, Ibrahim M, McCulloch P, Sujan M, Willars J, Mackintosh N. Am I safe? An Interpretative Phenomenological Analysis of Vulnerability as Experienced by Patients With Complications Following Surgery. QUALITATIVE HEALTH RESEARCH 2022; 32:2078-2089. [PMID: 36321384 PMCID: PMC9709529 DOI: 10.1177/10497323221136956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Abdominal surgery carries with it risks of complications. Little is known about patients' experiences of post-surgical deterioration. There is a real need to understand the psychosocial as well as the biological aspects of deterioration in order to improve care and outcomes for patients. Drawing on in-depth interviews with seven abdominal surgery survivors, we present an idiographic account of participants' experiences, situating their contribution to safety within their personal lived experiences and meaning-making of these episodes of deterioration. Our analysis reveals an overarching group experiential theme of vulnerability in relation to participants' experiences of complications after abdominal surgery. This encapsulates the uncertainty of the situation all the participants found themselves in, and the nature and seriousness of their health conditions. The extent of participants' vulnerability is revealed by detailing how they made sense of their experience, how they negotiated feelings of (un)safety drawing on their relationships with family and staff and the legacy of feelings they were left with when their expectations of care (care as imagined) did not meet the reality of their experiences (care as received). The participants' experiences highlight the power imbalance between patients and professionals in terms of whose knowledge counts within the hospital context. The study reveals the potential for epistemic injustice to arise when patients' concerns are ignored or dismissed. Our data has implications for designing strategies to enable escalation of care, both in terms of supporting staff to deliver compassionate care, and in strengthening patient and family involvement in rescue processes.
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Affiliation(s)
- Elizabeth Sutton
- Department of Health Sciences,
University
of Leicester, Leicester, UK
| | | | - Mudathir Ibrahim
- Nuffield Department of Surgical
Sciences, University of Oxford, Oxford, UK
- Department of General Surgery,
Maimonides
Medical Center, Brooklyn, NY, USA
| | - Peter McCulloch
- Nuffield Department of Surgical
Sciences, University of Oxford, Oxford, UK
| | - Mark Sujan
- Nuffield Department of Surgical
Sciences, University of Oxford, Oxford, UK
- Human Factors Everywhere
Ltd., UK
| | - Janet Willars
- Department of Health Sciences,
University
of Leicester, Leicester, UK
| | - Nicola Mackintosh
- Department of Health Sciences,
University
of Leicester, Leicester, UK
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Bunkenborg G, Barfod O'Connell M, Jensen HI, Bucknall T. Balancing responsibilities, rewards and challenges: A qualitative study illuminating the complexity of being a rapid response team nurse. J Clin Nurs 2022; 31:3560-3572. [PMID: 34985170 PMCID: PMC9787103 DOI: 10.1111/jocn.16183] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/26/2021] [Accepted: 12/09/2021] [Indexed: 12/30/2022]
Abstract
AIM AND OBJECTIVE To explore Rapid Response Team nurses' perceptions of what it means being a Rapid Response Team nurse including their perceptions of the collaborative and organisational aspects of the rapid response team (RRT). BACKGROUND For more than 20 years, RRT nurses have been on the frontline of critical situations in acute care hospitals. However, a few studies report nurses' perceptions of their role as RRT nurses, including collaboration with general ward nurses and physicians. This knowledge is important to guide development and adjustment of the RRT to benefit both patients' safety and team members' job satisfaction. DESIGN Qualitative focus group interviews. METHODS A qualitative approach was applied. Throughout 2018 and across three regions and three acute care settings in Denmark, eight focus group interviews were conducted in which 27 RRT nurses participated. Transcribed interviews were analysed using inductive content analysis. Reporting of this study followed the COREQ checklist. RESULTS One overarching theme 'Balancing responsibilities, rewards, and challenges' was derived, comprising six categories: 'Becoming, developing and fulfilling the RRT nurse role', 'Helping patients as the core function of RRT', 'The RRT-call at its best', 'The obvious and the subtle RRT tasks', 'Carrying the burden of the RRT', and 'Organisational benefits and barriers for an optimal RRT'. CONCLUSION Being a RRT nurse is a complex task. Nurses experience professional satisfaction and find it meaningful helping deteriorating patients. The inadequate resources available to train general ward staff how to manage basic clinical tasks are an added stress to nurses. RELEVANCE TO CLINICAL PRACTICE Organisational managers need a better understanding of the necessary staffing requirements to attend patients' needs, train staff and handle the increasing acuity of ward patients. Failure to do so will be detrimental to patient outcomes and compromise RRT nurses' job satisfaction.
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Affiliation(s)
- Gitte Bunkenborg
- Department of Intensive Care and AnaesthesiologyHolbæk HospitalHolbækDenmark,Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark
| | | | - Hanne Irene Jensen
- Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark,Department of Intensive Care and AnaesthesiologyLillebaelt HospitalUniversity Hospital of Southern DenmarkKoldingDenmark
| | - Tracey Bucknall
- Department of Regional Health ResearchUniversity of Southern DenmarkOdenseDenmark,Alfred Health Centre for Quality and Patient Safety ResearchInstitute of Health TransformationDeakin UniversityBurwoodVictoriaAustralia
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Bucknall TK, Considine J, Harvey G, Graham ID, Rycroft-Malone J, Mitchell I, Saultry B, Watts JJ, Mohebbi M, Bohingamu Mudiyanselage S, Lotfaliany M, Hutchinson A. Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO): a pragmatic cluster randomised controlled trial evaluating the effectiveness of a facilitation intervention on recognition and response to clinical deterioration. BMJ Qual Saf 2022; 31:818-830. [PMID: 35450936 PMCID: PMC9606509 DOI: 10.1136/bmjqs-2021-013785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 03/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Most hospitals use physiological signs to trigger an urgent clinical review. We investigated whether facilitation could improve nurses' vital sign measurement, interpretation, treatment and escalation of care for deteriorating patients. METHODS In a pragmatic cluster randomised controlled trial, we randomised 36 inpatient wards at four acute hospitals to receive standard clinical practice guideline (CPG) dissemination to ward staff (n=18) or facilitated implementation for 6 months following standard dissemination (n=18). Expert, hospital and ward facilitators tailored facilitation techniques to promote nurses' CPG adherence. Patient records were audited pre-intervention, 6 and 12 months post-intervention on randomly selected days. Escalation of care as per hospital policy was the primary outcome at 6 and 12 months after implementation. Patients, nurses and assessors were blinded to group assignment. Analysis was by intention-to-treat. RESULTS From 10 383 audits, improved escalation as per hospital policy was evident in the intervention group at 6 months (OR 1.47, 95% CI (1.06 to 2.04)) with a complete set of vital sign measurements sustained at 12 months (OR 1.22, 95% CI (1.02 to 1.47)). There were no significant differences in escalation of care as per hospital policy between study groups at 6 or 12 months post-intervention. After adjusting for patient and hospital characteristics, a significant change from T0 in mean length of stay between groups at 12 months favoured the intervention group (-2.18 days, 95% CI (-3.53 to -0.82)). CONCLUSION Multi-level facilitation significantly improved escalation as per hospital policy at 6 months in the intervention group that was not sustained at 12 months. The intervention group had increased vital sign measurement by nurses, as well as shorter lengths of stay for patients at 12 months. Further research is required to understand the dose of facilitation required to impact clinical practice behaviours and patient outcomes. TRIAL REGISTRATION NUMBER ACTRN12616000544471p.
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Affiliation(s)
- Tracey K Bucknall
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
- Centre for Quality and Patient Safety Research - Alfred Health Partnership, Alfred Health, Melbourne, Victoria, Australia
| | - Julie Considine
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
- Centre for Quality and Patient Safety Research - Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| | - Gillian Harvey
- Caring Futures Institute, Flinders University College of Nursing and Health Sciences, Bedford Park, South Australia, Australia
| | - Ian D Graham
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
- School of Epidemiology and Public Health and School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Imogen Mitchell
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Bridey Saultry
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
- Centre for Quality and Patient Safety Research - Alfred Health Partnership, Alfred Health, Melbourne, Victoria, Australia
| | - Jennifer J Watts
- School of Health and Social Development, Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Mohammadreza Mohebbi
- Biostatistics Unit, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Shalika Bohingamu Mudiyanselage
- School of Health and Social Development, Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Mojtaba Lotfaliany
- Biostatistics Unit, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Alison Hutchinson
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
- Centre for Quality and Patient Safety Research - Monash Health Partnership, Monash Health, Clayton, Victoria, Australia
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Olsen SL, Søreide E, Hansen BS. We Are Not There Yet: A Qualitative System Probing Study of a Hospital Rapid Response System. J Patient Saf 2022; 18:722-729. [PMID: 35384936 PMCID: PMC9524589 DOI: 10.1097/pts.0000000000001000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The capability of a hospital's rapid response system (RRS) depends on various factors to reduce in-hospital cardiac arrests and mortality. Through system probing, this qualitative study targeted a more comprehensive understanding of how healthcare professionals manage the complexities of RRS in daily practice as well as identifying its challenges. METHODS We observed RRS through in situ simulations in 2 wards and conducted the debriefings as focus group interviews. By arranging a separate focus group interview, we included the perspectives of intensive care unit personnel. RESULTS Healthcare professionals appreciated the standardized use of the National Early Warning Score, when combined with clinical knowledge and experience, structured communication, and interprofessional collaboration. However, we identified salient challenges in RRS, for example, unwanted variation in recognition competence, and inconsistent routines in education and documentation. Furthermore, we found that a lack of interprofessional trust, different understandings of RRS protocol, and signs of low psychological safety in the wards disrupted collaboration. To help remedy identified challenges, healthcare professionals requested shared arenas for learning, such as in situ simulation training. CONCLUSIONS Through system probing, we described the inner workings of RRS and revealed the challenges that require more attention. Healthcare professionals depend on structured RRS education, training, and resources to operate such a system. In this study, they request interventions like in situ simulation training as an interprofessional educational arena to improve patient care. This is a relevant field for further research. The Consolidated Criteria for Reporting Qualitative Studies Checklist was followed to ensure rigor in the study.
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Affiliation(s)
- Siri Lerstøl Olsen
- From the Department of Quality and Health Technology, The Faculty of Health Sciences, SHARE—Centre for Resilience in Healthcare, University of Stavanger
- Stavanger University Hospital, Stavanger, Norway
| | | | - Britt Sætre Hansen
- From the Department of Quality and Health Technology, The Faculty of Health Sciences, SHARE—Centre for Resilience in Healthcare, University of Stavanger
- Stavanger University Hospital, Stavanger, Norway
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Raff L, Reilly K, Ratner S, Moore C, Raff E. Building High-Performance Team Dynamics for Rapid Response Events in a US Tertiary Hospital: A Quality Improvement Model for Sustainable Process Change. Am J Med Qual 2022; 37:413-421. [PMID: 35404304 DOI: 10.1097/jmq.0000000000000057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hospital rapid response systems are designed to reduce unmet patient needs and prevent clinical deterioration. Rapid response teams are the principal component of a rapid response system and require teamwork to function optimally; poor communication among team members can result in substandard patient care. The authors describe a process for developing and implementing standardized communication and a teamwork structure for rapid response events (RREs) at a large academic hospital. The multidisciplinary team developed a project charter and key driver diagram, developed a "communication bundle," used quality improvement methodology, monitored adherence to the changes, and reported these data to key stakeholders on a weekly basis. By project end, the team met the goal of having 70% or more of adult RREs include the use of the "communication bundle." The balancing measure demonstrated that the introduction of a formalized communication framework did not significantly increase the duration of RREs.
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Affiliation(s)
- Lauren Raff
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Kelly Reilly
- Institute for Healthcare Quality and Improvement, University of North Carolina Health Care, Chapel Hill, NC
| | - Shana Ratner
- Institute for Healthcare Quality and Improvement, University of North Carolina Health Care, Chapel Hill, NC
- Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Carlton Moore
- Institute for Healthcare Quality and Improvement, University of North Carolina Health Care, Chapel Hill, NC
- Department of Medicine, Division of Hospital Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Evan Raff
- Department of Medicine, Division of Hospital Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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Girotra S, Jones P, Peberdy MA, Vaughan-Sarrazin M, Chan PS. Association of Rapid Response Teams With Hospital Mortality in Medicare Patients. Circ Cardiovasc Qual Outcomes 2022; 15:e008901. [PMID: 36065818 PMCID: PMC9489642 DOI: 10.1161/circoutcomes.122.008901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although rapid response teams have been widely promoted as a strategy to reduce unexpected hospital deaths, most studies of rapid response teams have not adjusted for secular trends in mortality before their implementation. We examined whether implementation of a rapid response team was associated with a reduction in hospital mortality after accounting for preimplementation mortality trends. METHODS Among 56 hospitals in Get With The Guidelines-Resuscitation linked to Medicare, we calculated the annual rates of case mix-adjusted mortality for each hospital during 2000 to 2014. We constructed a hierarchical log-binomial regression model of mortality over time (calendar-year), incorporating terms to capture the effect of rapid response teams, to determine whether implementation of rapid response teams was associated with reduction in hospital mortality that was larger than expected based on preimplementation trends, while adjusting for hospital case mix index. RESULTS The median annual number of Medicare admissions was 5214 (range, 408-18 398). The median duration of preimplementation and postimplementation period was 7.6 years (≈2.5 million admissions) and 7.2 years (≈2.6 million admissions), respectively. Hospital mortality was decreasing by 2.7% annually during the preimplementation period. Implementation of rapid response teams was not associated with a change in mortality during the initial year (relative risk for model intercept, 0.98 [95% CI, 0.94-1.02]; P=0.30) or in the mortality trend (relative risk for model slope, 1.01 per year [95% CI, 0.99-1.02]; P=0.30). Among individual hospitals, implementation of a rapid response team was associated with a lower-than-expected mortality at only 4 (7.1%) and higher-than-expected mortality at 2 (3.7%) hospitals. CONCLUSIONS Among a large and diverse sample of US hospitals, we did not find implementation of rapid response teams to be associated with reduction in hospital mortality. Studies are needed to understand best practices for rapid response team implementation, to ensure that hospital investment in these teams improves patient outcomes.
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Affiliation(s)
- Saket Girotra
- Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Philip Jones
- Saint Luke’s Mid-America Heart Institute, Kansas City, MO
| | - Mary Ann Peberdy
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA
| | - Mary Vaughan-Sarrazin
- Division of General Internal Medicine, University of Iowa Carver College of Medicine
- Comprehensive Access and Delivery Research and Evaluation, Veterans Affairs Medical Center, Iowa City
| | - Paul S. Chan
- Saint Luke’s Mid-America Heart Institute, Kansas City, MO
- University of Missouri, Kansas City, MO
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Shiao YC, Shen RN, Chen WW, Liu YP, Shih CL, Wang CC. Programme of triple-I mediator education (TIME) to improve medical disputes in clinical settings in Taiwan: a Delphi study. BMJ Open 2022; 12:e058880. [PMID: 36028268 PMCID: PMC9422892 DOI: 10.1136/bmjopen-2021-058880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Yi-Chih Shiao
- Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center; School of Medicine, National Defense Medical Center, Taipei, Taiwan
- College of Law, National Chengchi University, Taipei, Taiwan
| | | | | | - Yueh-Ping Liu
- Department of Medical Affairs, Ministry of Health and Welfare, Taipei, Taiwan
- Ministry of Health and Welfare, Taipei, Taiwan
| | | | - Chih-Chia Wang
- Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center; School of Medicine, National Defense Medical Center, Taipei, Taiwan
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Chen J, Ou L, Hillman K, Parr M, Flabouris A, Green M. Impact of a standardised rapid response system on clinical outcomes of female patients: an interrupted time series approach. BMJ Open Qual 2022; 11:bmjoq-2021-001614. [PMID: 35926982 PMCID: PMC9358951 DOI: 10.1136/bmjoq-2021-001614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 07/27/2022] [Indexed: 11/24/2022] Open
Abstract
Background This study aimed to assess the impact of a standardised rapid response systems (the Between the Flags (BTF)) implemented across New South Wales (NSW), Australia, among female patients. Methods We conducted an interrupted time series (2007–2013) population-based linkage study including 5 114 170 female patient (≥18 years old) admissions in all 232 public hospitals in NSW. We studied changes in levels and trends of patient outcomes after BTF implementation among four age groups of female patients. Results Before the BTF system introduction (2007–2009), for the female patients as a whole, there was a progressive decrease in rates of in-hospital cardiopulmonary arrest (IHCA), IHCA-related mortality and hospital mortality for female patients. However, there were no changes in deaths in low-mortality diagnostic-related groups (DLMDRGs), IHCA survival to discharge and 1-year post-discharge mortality after surviving an IHCA. Only the female patients aged 55 years and older showed the same results as the whole sample. After the BTF programme (2010–2013), the same trends (except for DLMDRG) continued for female patients as a whole and for those aged 55 years or older. There was a significant reduction in DLMDRG among female patients aged 35–54 years (p<0.001), those aged 75 years and over (p<0.05) and female patients as a whole (p<0.05). The decreasing secular trend of surviving an IHCA to hospital discharge before the BTF system (p<0.05) among patients aged 18–34 years old was reversed after the BTF implementation (p<0.01). Conclusions For female patients the BTF programme introduction was associated with continued reductions in the rates of IHCA, IHCA-related mortality and hospital mortality, as well as a new reduction in DLMDRG for 35–54 years old patients and those aged 75 years and older, and increased survival for those aged 18–34 years who had suffered an IHCA.
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Affiliation(s)
- Jack Chen
- The Simpson Centre for Health Services Research, University of New South Wales Faculty of Medicine, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Lixin Ou
- The Simpson Centre for Health Services Research, University of New South Wales Faculty of Medicine, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Ken Hillman
- The Simpson Centre for Health Services Research, University of New South Wales Faculty of Medicine, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Michael Parr
- Intensive Care Unit, Liverpool Hospital, University of New South Wales Faculty of Medicine, Sydney, New South Wales, Australia
- Intensive Care Unit, Maquaire University Hospital, Maquaire University, Sydney, New South Wales, Australia
| | - Arthas Flabouris
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Malcolm Green
- Clinical Excellence Commission, Sydney, New South Wales, Australia
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Considine J, Berry D, Doric A, Simpson J, Dwyer A, Hirth S, Newnham E. Frequency and nature of medical emergency team afferent limb failure in patients with documented vital sign abnormalities: A retrospective point prevalence study. Aust Crit Care 2022:S1036-7314(22)00069-8. [PMID: 35835654 DOI: 10.1016/j.aucc.2022.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 05/13/2022] [Accepted: 05/14/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Medical emergency team (MET) afferent limb failure is the presence of MET triggers and the absence of a documented MET call. OBJECTIVES The aim of this study was to measure and understand the frequency and nature of MET afferent limb failure in patients with documented vital sign abnormalities in an Australian major teaching hospital. METHODS A retrospective point prevalence study was conducted at a 600-bed teaching hospital in Melbourne, Australia. Data were collected for all adult inpatients (aged ≥18 years) on 13 wards (three general medicine, three surgical, and seven specialist wards) during a randomly selected 24-h period. Data were extracted from the electronic medical record. RESULTS There were 357 patients included in the study, with a median age of 72 y. Of the 9716 vital sign measures extracted, 0.9% fulfilled patient-specific MET activation criteria. There were 93 MET triggers documented in 36 patients: 25 patients experienced MET afferent limb failure. The major issues related to MET afferent limb failure were MET trigger modification processes, resolution of vital sign abnormalities, alternative escalation of care, and limitations of medical treatment orders without specific modifications to MET triggers. CONCLUSIONS Mandating MET activation for one aberrant vital sign at a single point in time warrants further assessment: lack of timely vital sign resolution may be a more appropriate trigger for MET calls and should be formally tested in future research. The frequency and effectiveness of alternative escalation pathways and local management of patients with MET triggers also warrant further investigation.
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Affiliation(s)
- Julie Considine
- Centre for Quality and Patient Safety Research - Eastern Health Partnership, 2/5 Arnold St, Box Hill, Victoria, 3128, Australia; Deakin University: School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria, 3220, Australia.
| | - Debra Berry
- Centre for Quality and Patient Safety Research - Eastern Health Partnership, 2/5 Arnold St, Box Hill, Victoria, 3128, Australia; Deakin University: School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute for Health Transformation, 1 Gheringhap St, Geelong, Victoria, 3220, Australia
| | - Andrea Doric
- Eastern Health, Arnold Street, Box Hill, Victoria, 3128, Australia
| | - Joanna Simpson
- Eastern Health, Arnold Street, Box Hill, Victoria, 3128, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, 5 Arnold St, Box Hill, Victoria, 3128, Australia
| | - Alison Dwyer
- Eastern Health, Arnold Street, Box Hill, Victoria, 3128, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, 5 Arnold St, Box Hill, Victoria, 3128, Australia
| | - Steven Hirth
- Eastern Health, Arnold Street, Box Hill, Victoria, 3128, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, 5 Arnold St, Box Hill, Victoria, 3128, Australia
| | - Evan Newnham
- Eastern Health, Arnold Street, Box Hill, Victoria, 3128, Australia; Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, 5 Arnold St, Box Hill, Victoria, 3128, Australia
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Kirby L, Chagan J, Adams C, Duns N, Haddad M, Pearson S, Tegg O, Goh CT. A Decade of Pediatric Intensive Care Outreach and the Deteriorating Child—The Relationship between Dose and Outcomes in a Tertiary Children's Hospital. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1750298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
AbstractThe aim of this study is to evaluate the amalgamation and maturation of a Pediatric Intensive Care Outreach Service (PICOS) with a rapid response system (RRS) and associated outcomes over a 10-year period. It is a single-center retrospective study analyzing patient outcomes within the context of significant organizational changes introducing a track and trigger RRS called Between the Flags (BTF) and evolution of this system to electronic observation charting and alerts (eBTF) in a tertiary metropolitan children's hospital. Children on inpatient wards who required urgent activation of the RRS and admission to the pediatric intensive care unit (PICU) between 2009 and 2018 were included. Three cohorts were identified according to the system changes—pre-BTF (2009–2011), BTF (2012–2017), and eBTF (2017–2018). The PICOS dose (number of activations per 1000 hospital admissions) increased with the introduction of BTF and the RRS and this trend continued following eBTF. The number of PICU admissions via the PICOS did not vary across the decade. When comparing the pre-BTF to the BTF group, PICU mortality decreased (p < 0.05), Pediatric Index of Mortality 2 Risk of Death scores improved, and hospital length of stay decreased (p < 0.05) in the BTF group. Introduction of a track and trigger RRS and electronic charting augmenting an existing PICOS is associated with increasing dose and workload, with no significant impact on PICU admission rates or length of stay. PICOS patient mortality has notably decreased with the introduction of an RRS; however, this impact was not sustained with the addition of electronic charting and alerts in the patient medical record.
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Affiliation(s)
- Lynette Kirby
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Jayshan Chagan
- School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - Catherine Adams
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Natalie Duns
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Michael Haddad
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Sarah Pearson
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Oliver Tegg
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Chong Tien Goh
- Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Pritchard ALM, Chin KL, Story DA, Smart P, Jones DA, See E, Nazareth JM. The epidemiology of rapid response team activation amongst patients undergoing major gastrointestinal surgery. Aust Crit Care 2022:S1036-7314(22)00059-5. [DOI: 10.1016/j.aucc.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/16/2022] [Accepted: 04/19/2022] [Indexed: 10/18/2022] Open
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Roasio A, Costanzo E, Bergesio G, Bosso S, Longu S, Zapparoli F, Bertocchini S, Forno G, Fogliati A, Novelli MT. Impact of the Proactive Rounding Team on Rapid Response System During COVID-19 Pandemic: A Retrospective Study From an Italian Medical Center. Cureus 2022; 14:e24432. [PMID: 35637817 PMCID: PMC9128792 DOI: 10.7759/cureus.24432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2022] [Indexed: 11/05/2022] Open
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Muñoz-Rojas G, García-Lorenzo B, Esteve D, Trias S, Caellas D, Sanz M, Mellado R, Peix T, Sampietro-Colom L, Pou N, Martínez-Pallí G, Ferrando C. Implementing a Rapid Response System in a tertiary-care hospital. A cost-effectiveness study. J Clin Monit Comput 2022; 36:1263-1269. [PMID: 35460504 DOI: 10.1007/s10877-022-00859-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/29/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE The occurrence of adverse events (AE) in hospitalized patients substancially increases the risk of disability or death, having a major negative clinical and economic impact on public health. For early identification of patients at risk and to establish preventive measures, different healthcare systems have implemented rapid response systems (RRS). The aim of this study was to carry out a cost-effectiveness analysis of implementing a RRS in a tertiary-care hospital. METHODS We included all the patients admitted to Hospital Clínic de Barcelona from 1 to 2016 to 31 December 2016. The cost-effectiveness analysis was summarized as the incremental cost-effectiveness ratio (incremental cost divided by the incremental effectiveness of the two alternatives, RRS versus non-RRS). The effectiveness of the RRS, defined as improvements in health outcomes (AE, cardiopulmonary arrest and mortality), was obtained from the literature and applied to the included patient cohort. A budget impact analysis on the implementation of the RRS from a hospital perspective was performed over a 5-year time horizon. RESULTS 42,409 patients were included, and 448 (1.05%) had severe AE requiring ICU admission. The cost-effectiveness analysis showed an incremental cost (savings) of EUR - 1,471,101 of RRS versus the non-RRS. The budgetary impact showed a cost reduction of EUR 896,762.00 in the first year and EUR 1,588,579.00 from the second to the fifth year. CONCLUSIONS The present analysis shows the RRS as a dominant, less costly and more effective structure compared to the non-RRS.
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Affiliation(s)
- G Muñoz-Rojas
- Department of Anesthesiology and Critical Care, Hospital Clínic de Barcelona, Institut D'investigació August Pi i Sunyer, C/ Villarroel 170, 08036, Barcelona, Spain
| | - B García-Lorenzo
- Assessment of Innovations and New Technologies Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- Kronikgune Institute for Health Services Research, Barakaldo, Basque Country, Spain
| | - D Esteve
- Respiratory Intensive Care Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - S Trias
- Surgical Area Management, Hospital Clínic de Barcelona, Barcelona, Spain
| | - D Caellas
- Information Systems Management, Hospital Clínic de Barcelona, Barcelona, Spain
| | - M Sanz
- Infrastructure Management, Hospital Clínic de Barcelona, Barcelona, Spain
| | - R Mellado
- Department of Anesthesiology and Critical Care, Hospital Clínic de Barcelona, Institut D'investigació August Pi i Sunyer, C/ Villarroel 170, 08036, Barcelona, Spain
- CIBER (Center of Biomedical Research in Respiratory Diseases), Instituto de Salud Carlos III, Madrid, Spain
| | - T Peix
- Surgical Area Management, Hospital Clínic de Barcelona, Barcelona, Spain
| | - L Sampietro-Colom
- Assessment of Innovations and New Technologies Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - N Pou
- Surgical Area Management, Hospital Clínic de Barcelona, Barcelona, Spain
| | - G Martínez-Pallí
- Department of Anesthesiology and Critical Care, Hospital Clínic de Barcelona, Institut D'investigació August Pi i Sunyer, C/ Villarroel 170, 08036, Barcelona, Spain
- CIBER (Center of Biomedical Research in Respiratory Diseases), Instituto de Salud Carlos III, Madrid, Spain
| | - Carlos Ferrando
- Department of Anesthesiology and Critical Care, Hospital Clínic de Barcelona, Institut D'investigació August Pi i Sunyer, C/ Villarroel 170, 08036, Barcelona, Spain.
- CIBER (Center of Biomedical Research in Respiratory Diseases), Instituto de Salud Carlos III, Madrid, Spain.
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Berry D, Street M, Hall K, Sprogis SK, Considine J. Recognising and Responding to Clinical Deterioration in Adult Patients in Isolation Precautions for Infection Control: A Retrospective Cohort Study. Int J Qual Health Care 2022; 34:6552208. [PMID: 35323935 DOI: 10.1093/intqhc/mzac020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 02/02/2022] [Accepted: 03/21/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patient isolation is widely used as a strategy for prevention and control of infection but may have unintended consequences for patients. Early recognition and response to acute deterioration is an essential component of safe, quality patient care and has not been explored for patients in isolation. Primary aims of this study were to: i) describe the timing, frequency, and nature of clinical deterioration during hospital admission for patients with isolation precautions for infection control and ii) compare the characteristics of patients who did and did not deteriorate during their initial period of isolation precautions for infection control. METHODS This retrospective cohort study was conducted across three sites of a large Australian health service. The study sample were adult patients (≥18 years) admitted into isolation precautions within 24-hours of admission from 1 July to 31 December 2019. RESULTS There were 634 patients who fulfilled the study inclusion criteria. One in eight patients experienced at least one episode of clinical deterioration during their time in isolation with most episodes of deterioration occurring within the first two days of admission. Timely Medical Emergency Team calls occurred in almost half the episodes of deterioration; however, the same proportion (47.2%) of deterioration episodes resulted in no Medical Emergency Team activation (afferent limb failure). In the 24-hours preceding each episode of clinical deterioration (n=180), 81.6% (n=147) of episodes were preceded by vital signs fulfilling pre-Medical Emergency Team criteria.Patients who deteriorated during isolation for infection control were older (median age 74.0 vs 71.0 years, P=0.042); more likely to live in a residential care facility (21.0% vs 7.2%, P=0.006); had a longer initial period of isolation (4.0 vs 2.9 days, P=<000.1) and hospital length of stay (median 4.9 vs 3.2 days, P=<0.001) and were more likely to die in hospital (12.3% vs 4.3%, P<0.001). CONCLUSION Patients in isolation precautions experienced high Medical Emergency Team afferent limb failure and most fulfilled pre-Medical Emergency Team criteria in the 24-hours preceding episodes of deterioration. Timely recognition and response to clinical deterioration continue to be essential in providing safe, quality patient care regardless of the hospital-care environment.
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Affiliation(s)
- D Berry
- Centre for Quality and Patient Safety - Eastern Health Partnership, Box Hill, Vic, Australia.,School of Nursing and Midwifery & Institute for Health Transformation, Deakin University, Geelong, Vic, Australia.,School of Nursing and Midwifery, Centre for Quality and Patient Safety Research & Institute for Health Transformation, Deakin University, Geelong, Vic, Australia
| | - M Street
- Centre for Quality and Patient Safety - Eastern Health Partnership, Box Hill, Vic, Australia.,School of Nursing and Midwifery & Institute for Health Transformation, Deakin University, Geelong, Vic, Australia.,School of Nursing and Midwifery, Centre for Quality and Patient Safety Research & Institute for Health Transformation, Deakin University, Geelong, Vic, Australia
| | - K Hall
- Eastern Health, Box Hill, Vic, Australia
| | - S K Sprogis
- School of Nursing and Midwifery & Institute for Health Transformation, Deakin University, Geelong, Vic, Australia
| | - J Considine
- Centre for Quality and Patient Safety - Eastern Health Partnership, Box Hill, Vic, Australia.,School of Nursing and Midwifery & Institute for Health Transformation, Deakin University, Geelong, Vic, Australia.,School of Nursing and Midwifery, Centre for Quality and Patient Safety Research & Institute for Health Transformation, Deakin University, Geelong, Vic, Australia
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Lee SI, Koh JS, Kim YJ, Kang DH, Lee JE. Characteristics and outcomes of patients screened by rapid response team who transferred to the intensive care unit. BMC Emerg Med 2022; 22:18. [PMID: 35114944 PMCID: PMC8811968 DOI: 10.1186/s12873-022-00575-y] [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: 06/17/2021] [Accepted: 01/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The utilization of a rapid response team (RRT) has influenced the clinical outcomes of patients in the general ward. However, the characteristics of RRT-screened patients who are transferred to the intensive care unit (ICU) are unknown. Therefore, the present study aimed to evaluate these factors. METHODS We conducted a retrospective study using patient data from a tertiary medical center in Republic of Korea between January 2016 and December 2017. Multivariate logistic regression analyses were performed to assess the factors associated with the risk of in-hospital mortality. RESULTS A total of 1,096 patients were included: 389 patients were transferred to the ICU, and 707 patients stayed in the ward. Patients in the ICU group were more likely to be admitted for medical reasons, hepatobiliary disease, and high heart rate. More interventions were performed, hospital stays were longer, and the 28-day and in-hospital mortality rates were higher in the ICU group than in the ward group. Multivariate logistic regression analyses showed that risk factors affecting ICU admission were higher Sequential Organ Failure Assessment (SOFA) score, National Early Warning Score (NEWS), platelet count, and lactate level. ICU transfer was not associated with in-hospital mortality. CONCLUSIONS Among RRT-screened patients, those with higher SOFA score, NEWS, and lactate level were more likely to be transferred to the ICU. Therefore, these patients should be closely monitored and considered for ICU transfer.
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Affiliation(s)
- Song-I Lee
- Department of Pulmonary and Critical Care Medicine, Chungnam National University School of Medicine, 33 Munhwa-ro, Jung-gu, 301-721, Daejeon, Republic of Korea
| | - Jeong Suk Koh
- Department of Pulmonary and Critical Care Medicine, Chungnam National University School of Medicine, 33 Munhwa-ro, Jung-gu, 301-721, Daejeon, Republic of Korea
| | - Yoon Joo Kim
- Department of Pulmonary and Critical Care Medicine, Chungnam National University School of Medicine, 33 Munhwa-ro, Jung-gu, 301-721, Daejeon, Republic of Korea
| | - Da Hyun Kang
- Department of Pulmonary and Critical Care Medicine, Chungnam National University School of Medicine, 33 Munhwa-ro, Jung-gu, 301-721, Daejeon, Republic of Korea
| | - Jeong Eun Lee
- Department of Pulmonary and Critical Care Medicine, Chungnam National University School of Medicine, 33 Munhwa-ro, Jung-gu, 301-721, Daejeon, Republic of Korea.
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50
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Jung H, Ko RE, Ko MG, Jeon K. Trends of in-hospital cardiac arrests in a single tertiary hospital with a mature rapid response system. PLoS One 2022; 17:e0262541. [PMID: 35025978 PMCID: PMC8757966 DOI: 10.1371/journal.pone.0262541] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Most studies on rapid response system (RRS) have simply focused on its role and effectiveness in reducing in-hospital cardiac arrests (IHCAs) or hospital mortality, regardless of the predictability of IHCA. This study aimed to identify the characteristics of IHCAs including predictability of the IHCAs as our RRS matures for 10 years, to determine the best measure for RRS evaluation. Methods Data on all consecutive adult patients who experienced IHCA and received cardiopulmonary resuscitation in general wards between January 2010 and December 2019 were reviewed. IHCAs were classified into three groups: preventable IHCA (P-IHCA), non-preventable IHCA (NP-IHCA), and inevitable IHCA (I-IHCA). The annual changes of three groups of IHCAs were analyzed with Poisson regression models. Results Of a total of 800 IHCA patients, 149 (18.6%) had P-IHCA, 465 (58.1%) had NP-IHCA, and 186 (23.2%) had I-IHCA. The number of the RRS activations increased significantly from 1,164 in 2010 to 1,560 in 2019 (P = 0.009), and in-hospital mortality rate was significantly decreased from 9.20/1,000 patients in 2010 to 7.23/1000 patients in 2019 (P = 0.009). The trend for the overall IHCA rate was stable, from 0.77/1,000 patients in 2010 to 1.06/1,000 patients in 2019 (P = 0.929). However, while the incidence of NP-IHCA (P = 0.927) and I-IHCA (P = 0.421) was relatively unchanged over time, the incidence of P-IHCA decreased from 0.19/1,000 patients in 2010 to 0.12/1,000 patients in 2019 (P = 0.025). Conclusions The incidence of P-IHCA could be a quality metric to measure the clinical outcomes of RRS implementation and maturation than overall IHCAs.
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Affiliation(s)
- Hohyung Jung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myeong Gyun Ko
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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