Association between frailty and clinical outcomes in hospitalised patients requiring Code Blue activation

BACKGROUND

Code Blues allow a rapid, hospital wide response to acutely deteriorating patients. The concept of frailty is being increasingly recognised as an important element in determining outcomes of critically ill patients. We hypothesised that increasing frailty would be associated with worse outcomes following a Code Blue.

AIMS

To investigate the association between increasing frailty and outcomes of Code Blues.

METHODS

Single-centre retrospective design of patients admitted to Frankston Hospital in Australia between 1 January 2013 and 31 December 2017 who triggered a Code Blue. Frailty evaluation was made based on electronic medical records as were the details and the outcomes of the Code Blue. The primary outcome measure was a composite of hospital mortality or Cerebral Performance Categories scale ≥3. Secondary outcomes included the immediate outcome of the Code Blue and hospital mortality.

RESULTS

One hundred and forty-eight of 911 screened patients were included in the final analysis. Seventy-three were deemed 'frail' and the remainder deemed 'fit'. Seventy-eight  percent of frail patients reached the primary outcome, compared with 41% of fit patients (P < 0.001). Multivariable analysis demonstrated frailty to be associated with primary outcome (odds ratio = 2.87; 95% confidence interval (CI) 1.28-6.44; P = 0.01). A cardiac aetiology for the Code Blue was also associated with an increased odds of primary outcome (OR = 3.52; 95% CI 1.51-8.05; P = 0.004).

CONCLUSIONS

Frailty is independently associated with the composite outcome of hospital mortality or severe disability following a Code Blue. Frailty is an important tool in prognostication for these patients and might aid in discussions regarding treatment limitations.

Obstetric Emergencies requiring Rapid response team activation: A retrospective cohort study in a high-risk tertiary care centre

OBJECTIVE

The purpose of this study was to better understand obstetric codes requiring rapid response team (RRT) activation by examining their incidence, indications, team response and patient outcomes.

METHODS

This was a retrospective study in peripartum women who required activation of "Code 77 (C77)" (obstetric emergency), "Code Blue (CB)" (cardiopulmonary compromise) or "Code Omega (CO)" (massive transfusion) during hospitalization during January 2014-May 2018. Hospital database and health records were interrogated to identify and review cases. Data on code characteristics, resuscitative measures, and maternal/ neonatal outcomes were collected.

RESULTS

147 codes were identified (C77, n=110; CO, n=25; CB, n=12) during the study period, with an incidence of 1:203 deliveries (C77 - 1:271 deliveries, CO - 1:1,194 deliveries and CB - 1:2,488 deliveries). The common indications for C77 were cord prolapse (33%) and fetal bradycardia (32%), and for CO and CB were postpartum hemorrhage (84%) and cardiac arrest (42%), respectively. Most (67%) codes occurred afterhours. The median (IQR) decision-to-delivery interval (DDI) was 8 (5, 15) min after C77. Emergency cesarean delivery (CD) was performed after 57% of obstetric emergencies and general anesthesia was administered in 63% of CDs. Maternal and neonatal mortality rates were 0.68% and 7%, respectively. Major maternal morbidity was seen in 33% cases. Debrief was documented in 4% codes.

CONCLUSION

RRT activation was required more commonly in C77 than in CO or CB. Their response time and DDIs were rapid. Mortality was low, however, one-third parturients had major morbidity. We suggest closer patient monitoring, immediate availability of resources, and appropriate documentation and debriefing.

Cardiopulmonary Arrest and Resuscitation in the Prone Patient: An Adult Simulation Case for Internal Medicine Residents

INTRODUCTION

Acute respiratory distress syndrome (ARDS) is present in approximately 10% of ICU admissions and is associated with great morbidity and mortality. Prone ventilation has been shown to improve refractory hypoxemia and mortality in patients with ARDS.

METHODS

In this simulation, a 70-year-old male had been transferred to the ICU for ARDS and was undergoing scheduled prone ventilation as part of his care when he experienced a cardiopulmonary arrest secondary to a tension pneumothorax. Learners demonstrated how to manage cardiac arrest in a prone patient and subsequently identified and treated the tension pneumothorax that was the cause of his initial arrest. This single-session simulation for internal medicine residents (PGY 1-PGY 4) utilized a prone mannequin connected to a ventilator in a high-fidelity simulation center. Following the simulation, facilitators led a team debriefing and reviewed key learning objectives.

RESULTS

A total of 103 internal medicine residents participated in this simulation. Of those, 43 responded to a postsimulation survey. Forty-two of 43 agreed or strongly agreed that all learning objectives were met, that the simulation was appropriate for their level of training, and that their participation would be useful for their future practice.

DISCUSSION

We designed this simulation to improve learners' familiarity with prone cardiopulmonary resuscitation and to enhance overall comfort with cardiac arrest management. Postsimulation survey results and debriefings revealed that the simulation was a valuable education opportunity, and learners felt that their participation in this simulation would be helpful in their future practice.

Code Blue evaluation in children's hospital

BACKGROUND

True alarm rate of the Code Blue cases is at a low level in the Dr. Behçet Uz Children's Hospital in İzmir. This study aims to analyse the use of the Code Blue alarm cases in the children's hospital.

METHODS

This retrospective clinical study evaluated the age and the gender of the cases, the arriving time of the Code Blue team, the date and time of the Code Blue Call, the reasons of the Code Blue Call, and the verification which were all obtained from the Code Blue forms of the hospital dated between January 2014 and January 2015. The data of 139 Code Blue cases' forms were investigated and was divided into two groups: before and after the education containing 88 and 51 cases, respectively.

RESULTS

Conversive disorder (26% to 13%, P<0.01), syncope (21.5% to 19.6%, P<0.01), convulsion (17% to 13.7%, P<0.01), hypoglycemia (4.5% to 3.9%, P<0.01), anxiety (4.5% to 1.9%, P<0.01), head trauma due to syncope (4.5% to 0%), cardiac arrest (1.1% to 0%), respiratory difficulties (2.2% to 1.9%, P<0.01), suspicion of myocardial infarction (2.2% to 1.9%, P<0.01), fall from stairs (2.2% to 0%) and agitation cases (1.1% to 0%) were reduced, however, the hypertension cases were dramatically increased (3.4% to 29.4%, P<0.01) owing to the hospital staff's education. The Pearson's correlation coefficient before and after education was 0.837. About 97.8% of the Code Blue cases were false calls with female greater than male (P<0.01).

CONCLUSION

The results of this study show that more education is required for the hospital's staff and a new color code that is to say pre-diagnosis team should be formed.