1
|
Jeong H, Choi JW, Kim DK, Lee SH, Lee SY. Implementation and Outcomes of a Difficult Airway Code Team Composed of Anesthesiologists in a Korean Tertiary Hospital: A Retrospective Analysis of a Prospective Registry. J Korean Med Sci 2022; 37:e21. [PMID: 35040296 PMCID: PMC8763879 DOI: 10.3346/jkms.2022.37.e21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 11/21/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In 2017, we established an airway call (AC) team composed of anesthesiologists to improve emergency airway management outside the operating room. In this retrospective analysis of prospectively collected data from the airway registry, we describe the characteristics of patients attended to and practices by the AC team during the first 4 years of implementation. METHODS All AC team activations in which an airway intervention was performed by the AC team between June 2017 and May 2021 were analyzed. RESULTS In all, 359 events were analyzed. Activation was more common outside of working hours (62.1%) and from the intensive care unit (85.0%); 36.2% of AC activations were due to known or anticipated difficult airway, most commonly because of acquired airway anomalies (n = 49), followed by airway edema or bleeding (n = 32) and very young age (≤ 1 years; n = 30). In 71.3% of the cases, successful intubation was performed by the AC team at the first attempt. However, three or more attempts were performed in 33 cases. The most common device used for successful intubation was the videolaryngoscope (59.7%). Tracheal intubation by the AC team failed in nine patients, who then required surgical airway insertion by otolaryngologists. However, there were no airway-related deaths. CONCLUSIONS When coupled with appropriate assistance from an otolaryngologist AC system, an AC team composed of anesthesiologists could be an efficient way to provide safe airway management outside the operating room. TRIAL REGISTRATION Clinical Research Information Service Identifier: KCT0006643.
Collapse
Affiliation(s)
- Heejoon Jeong
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Duk Kyung Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Yeon Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
2
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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:
| |
Collapse
|
3
|
Kim SH, Hong JY, Kim Y. Characteristics and Prognosis of Hospitalized Patients at High Risk of Deterioration Identified by the Rapid Response System: a Multicenter Cohort Study. J Korean Med Sci 2021; 36:e235. [PMID: 34402231 PMCID: PMC8369309 DOI: 10.3346/jkms.2021.36.e235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/27/2021] [Indexed: 11/20/2022] Open
Abstract
We aimed to investigate the characteristics and prognosis of high risk hospitalized patients identified by the rapid response system (RRS). A multicentered retrospective cohort study was conducted from June 2019 to December 2020. The National Early Warning Score (NEWS) was used for RRS activation. The outcome was unexpected intensive care unit (ICU) admission within 24 hours after RRS activation. The 11,459 patients with RRS activations were included. We found distinct clinical characteristics in patients who underwent ICU admission. All NEWS parameters were associated with the risk of unexpected ICU admission except body temperature. Body mass index, pulmonary disease, and cancer are related to the decreased risk of unexpected ICU admission. In conclusion, there were differences in clinical characteristics among high risk patients, and those differences were associated with unexpected ICU admissions. Clinicians should consider factors relating to unexpected ICU admission in the management of high risk patients identified by RRS.
Collapse
Affiliation(s)
- Sang Hyuk Kim
- Division of Pulmonology and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Young Hong
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Korea
| | - Youlim Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Korea.
| |
Collapse
|
4
|
Hosokawa K, Kamada H, Ota K, Yamaga S, Ishii J, Shime N. Prevalence of rapid response systems in small hospitals: A questionnaire survey. Medicine (Baltimore) 2021; 100:e26261. [PMID: 34115019 PMCID: PMC8202584 DOI: 10.1097/md.0000000000026261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 05/24/2021] [Indexed: 01/04/2023] Open
Abstract
The rapid response system (RRS) was introduced for early stage intervention in patients with deteriorating clinical conditions. Responses to unexpected in-hospital patient emergencies varied among hospitals. This study was conducted to understand the prevalence of RRS in smaller hospitals and to identify the need for improvements in the responses to in-hospital emergencies.A questionnaire survey of 971 acute-care hospitals in western Japan was conducted from May to June 2019 on types of in-hospital emergency response for patients in cardiac arrest (e.g., medical emergency teams [METs]), before obvious deterioration (e.g., rapid response teams [RRTs]), and areas for improvement.We received 149 responses, including those from 56 smaller hospitals (≤200 beds), which provided fewer responses than other hospitals. Response systems for cardiac arrest were used for at least a limited number of hours in 129 hospitals (87%). The absence of RRS was significantly more frequent in smaller hospitals than in larger hospitals (13/56, 23% vs 1/60, 2%; P < .01). METs and RRTs operated in 17 (11%) and 15 (10%) hospitals, respectively, and the operation rate for RRTs was significantly lower in smaller hospitals than in larger hospitals (1/56, 2% vs 12/60, 20%; P < .01). Respondents identified the need for education and more medical staff and supervisors; data collection or involvement of the medical safety management sector was ranked low.The prevalence of RRS or predetermined responses before obvious patient deterioration was ≤10% in small hospitals. Specific education and appointment of supervisors could support RRS in small hospitals.
Collapse
Affiliation(s)
- Koji Hosokawa
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 1-2-3 Kasumi, Minami-ku, Hiroshima
- Department of Anesthesiology and Reanimatology, Faculty of Medical Sciences, University of Fukui, 23-3 Eiheijicho, Yoshidagun, Fukui
| | - Hiroki Kamada
- Department of Medicine, Hiroshima University, Hiroshima, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Kohei Ota
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 1-2-3 Kasumi, Minami-ku, Hiroshima
| | - Satoshi Yamaga
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 1-2-3 Kasumi, Minami-ku, Hiroshima
| | - Junki Ishii
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 1-2-3 Kasumi, Minami-ku, Hiroshima
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, 1-2-3 Kasumi, Minami-ku, Hiroshima
| |
Collapse
|
5
|
Olu OO, Lako R, Bunga S, Berta K, Kol M, Ramadan PO, Ryan C, Udenweze I, Guyo AG, Conteh I, Huda Q, Gai M, Saulo D, Papowitz H, Gray HJ, Chimbaru A, Wangdi K, Grube SM, Barr BT, Wamala JF. Analyses of the performance of the Ebola virus disease alert management system in South Sudan: August 2018 to November 2019. PLoS Negl Trop Dis 2020; 14:e0008872. [PMID: 33253169 PMCID: PMC7728195 DOI: 10.1371/journal.pntd.0008872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 12/10/2020] [Accepted: 10/10/2020] [Indexed: 12/02/2022] Open
Abstract
South Sudan implemented Ebola virus disease preparedness interventions aiming at preventing and rapidly containing any importation of the virus from the Democratic Republic of Congo starting from August 2018. One of these interventions was a surveillance system which included an Ebola alert management system. This study analyzed the performance of this system. A descriptive cross-sectional study of the Ebola virus disease alerts which were reported in South Sudan from August 2018 to November 2019 was conducted using both quantitative and qualitative methods. As of 30 November 2019, a total of 107 alerts had been detected in the country out of which 51 (47.7%) met the case definition and were investigated with blood samples collected for laboratory confirmation. Most (81%) of the investigated alerts were South Sudanese nationals. The alerts were identified by health workers (53.1%) at health facilities, at the community (20.4%) and by screeners at the points of entry (12.2%). Most of the investigated alerts were detected from the high-risk states of Gbudwe (46.9%), Jubek (16.3%) and Torit (10.2%). The investigated alerts commonly presented with fever, bleeding, headache and vomiting. The median timeliness for deployment of Rapid Response Team was less than one day and significantly different between the 6-month time periods (K-W = 7.7567; df = 2; p = 0.0024) from 2018 to 2019. Strengths of the alert management system included existence of a dedicated national alert hotline, case definition for alerts and rapid response teams while the weaknesses were occasional inability to access the alert toll-free hotline and lack of transport for deployment of the rapid response teams which often constrain quick response. This study demonstrates that the Ebola virus disease alert management system in South Sudan was fully functional despite the associated challenges and provides evidence to further improve Ebola preparedness in the country. The Democratic Republic of Congo announced its tenth outbreak of the Ebola virus disease on 1st August 2018. As part of the preparedness measures to prevent and rapidly contain any importation of the virus, South Sudan, a neighbouring country to the Democratic Republic of Congo implemented a surveillance system which included an Ebola alert management system. We analyzed the performance of this system with a view to provide information to inform planning and allocation of resources to the other components of Ebola virus disease preparedness and to understand the key issues and challenges with the system. Our findings show that more than half of the reported alerts did not meet the case definition of the disease, alerts were mainly detected in the high-risk states, the commonest source of alert detection were from health facilities and the community and the most common symptoms presented by the alerts were fever, bleeding, headache, vomiting and weakness/fatigue. This study demonstrates that the Ebola virus disease alert management system in South Sudan was fully functional despite the associated challenges and provided evidence to further improve Ebola preparedness in the country. We recommend that the observed challenges should be urgently addressed.
Collapse
Affiliation(s)
- Olushayo Oluseun Olu
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Richard Lako
- National Ebola virus disease Incident Management Team Ministry of Health, Republic of South Sudan
| | - Sudhir Bunga
- United States Centers for Disease Control, Atlanta, Georgia, United States of America
| | - Kibebu Berta
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Matthew Kol
- National Ebola virus disease Incident Management Team Ministry of Health, Republic of South Sudan
| | - Patrick Otim Ramadan
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Caroline Ryan
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Ifeanyi Udenweze
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Argata Guracha Guyo
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Ishata Conteh
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Qudsia Huda
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Malick Gai
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Dina Saulo
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Heather Papowitz
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Henry John Gray
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Alex Chimbaru
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Kencho Wangdi
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| | - Steven M Grube
- United States Centers for Disease Control, Atlanta, Georgia, United States of America
| | - Beth Tippett Barr
- United States Centers for Disease Control, Atlanta, Georgia, United States of America
| | - Joseph Francis Wamala
- Ebola virus disease preparedness team, World Health Organization, Juba, Republic of South Sudan
| |
Collapse
|
6
|
Amir LD. Rapid Response Team Activations in an Israeli Tertiary Care Pediatric Hospital: Analysis of 614 Events. Isr Med Assoc J 2020; 22:384-389. [PMID: 32558446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Rapid response teams (RRT) reduce in-hospital mortality and cardiac arrests. There are only a few articles describing RRT activations outside of North America and Australia. OBJECTIVES To describe demographic and clinical variables of RRT activations using 13 years of data. METHODS Schneider Children's Medical Center of Israel is a pediatric hospital with the busiest pediatric emergency department in the country. We analyzed demographic and clinical data of RRT activation from 1 January 2008 to 31 December 2018. RESULTS During the study period there were 614 RRT activations with an average of 55.8 activations per year (range 43-76). RRT activations occurred most commonly for children aged 0-12 months (43%) as compared to children 1-5 years of age (25%), 6-10 years of age (12%), 11-18 years of age (18%), and adults (2%). The most common reason for activation was respiratory deterioration (45.8%) followed by neurologic alteration (21%), and cardiac arrest (18%). Following resuscitation, 47% of the patients were admitted to the pediatric intensive care unit and 12% were pronounced dead. Intubation was performed in 48.9% of activations, chest compressions in 20.5%, intraosseous line insertion in 9.4%, and defibrillation in 3.4%. Procedures were usually performed in the emergency department (ED). CONCLUSIONS We describe RRT including RRT activations in the ED. The high frequency of interventions should be utilized to direct staff training for the RRT and the ED. The lack of standardization of reporting data for RRT activations makes comparisons among hospitals difficult.
Collapse
Affiliation(s)
- Lisa D Amir
- Department of Emergency Medicine, Schneider Children's Medical Center, Petah Tikva, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
7
|
Xian X, Das D, Pasupathy KS, Boie ET, Sir M. Quantifying the Impact of Resuscitation-Team Activation in Hospital Emergency Departments. IEEE J Biomed Health Inform 2020; 24:3029-3037. [PMID: 32750911 DOI: 10.1109/jbhi.2020.2997562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Hospital emergency department (ED) operations are affected when critically ill or injured patients arrive. Such events often lead to the initiation of specific protocols, referred to as Resuscitation-team Activation (RA), in the ED of Mayo Clinic, Rochester, MN where this study was conducted. RA events lead to the diversion of resources from other patients in the ED to provide care to critically ill patients; therefore, it has an impact on the entire ED system. This paper presents a data-driven and flexible statistical learning model to quantify the impact of RA on the ED. The model learns the pattern of operations in the ED from historical patient arrival and departure timestamps and quantifies the impact of RA by measuring the deviation of the departure of patients during RA from normal processes. The proposed method significantly outperforms baseline methods based on measuring the average time patients spend in the ED.
Collapse
|
8
|
Chen QT, Hawker F. Modifications to predefined rapid response team calling criteria: prevalence, characteristics and associated outcomes. CRIT CARE RESUSC 2020; 22:86. [PMID: 32102648 PMCID: PMC10692445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
|
9
|
Dewan M, Muthu N, Shelov E, Bonafide CP, Brady P, Davis D, Kirkendall ES, Niles D, Sutton RM, Traynor D, Tegtmeyer K, Nadkarni V, Wolfe H. Performance of a Clinical Decision Support Tool to Identify PICU Patients at High Risk for Clinical Deterioration. Pediatr Crit Care Med 2020; 21:129-135. [PMID: 31577691 PMCID: PMC7007854 DOI: 10.1097/pcc.0000000000002106] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the translation of a paper high-risk checklist for PICU patients at risk of clinical deterioration to an automated clinical decision support tool. DESIGN Retrospective, observational cohort study of an automated clinical decision support tool, the PICU Warning Tool, adapted from a paper checklist to predict clinical deterioration events in PICU patients within 24 hours. SETTING Two quaternary care medical-surgical PICUs-The Children's Hospital of Philadelphia and Cincinnati Children's Hospital Medical Center. PATIENTS The study included all patients admitted from July 1, 2014, to June 30, 2015, the year prior to the initiation of any focused situational awareness work at either institution. INTERVENTIONS We replicated the predictions of the real-time PICU Warning Tool by retrospectively querying the institutional data warehouse to identify all patients that would have flagged as high-risk by the PICU Warning Tool for their index deterioration. MEASUREMENTS AND MAIN RESULTS The primary exposure of interest was determination of high-risk status during PICU admission via the PICU Warning Tool. The primary outcome of interest was clinical deterioration event within 24 hours of a positive screen. The date and time of the deterioration event was used as the index time point. We evaluated the sensitivity, specificity, positive predictive value, and negative predictive value of the performance of the PICU Warning Tool. There were 6,233 patients evaluated with 233 clinical deterioration events experienced by 154 individual patients. The positive predictive value of the PICU Warning Tool was 7.1% with a number needed to screen of 14 patients for each index clinical deterioration event. The most predictive of the individual criteria were elevated lactic acidosis, high mean airway pressure, and profound acidosis. CONCLUSIONS Performance of a clinical decision support translation of a paper-based tool showed inferior test characteristics. Improved feasibility of identification of high-risk patients using automated tools must be balanced with performance.
Collapse
Affiliation(s)
- Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Naveen Muthu
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Eric Shelov
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Patrick Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Daniela Davis
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Eric S. Kirkendall
- Department of Pediatrics, Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
| | - Dana Niles
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Danielle Traynor
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Heather Wolfe
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| |
Collapse
|
10
|
Levkovich BJ, Bingham G, Hopkins RE, Jones D, Cooper DJJ, Kirkpatrick CM, Dooley MJ. An Observational Analysis of Medication Use During 5,727 Medical Emergency Team Activations at a Tertiary Referral Hospital. Jt Comm J Qual Patient Saf 2019; 45:502-508. [PMID: 31027948 DOI: 10.1016/j.jcjq.2019.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Medical emergency teams (METs) rescue deteriorating patients as the response arm of hospital rapid response systems. This study aimed to (1) investigate medication use during MET activations by describing the type, frequency and access sources of medications; and (2) assess associations between patient characteristics, MET activation criteria, and outcomes and MET medication use. METHODS A single-center, retrospective study from a prospective database of MET activations in an Australian tertiary referral hospital was undertaken. Consecutive adult MET activations over a 12-month period were included. RESULTS Across the study period, there were 5,727 MET activations with medications used at 33.5% (n = 1,920). Of 2,648 medications used, cardiac system agents (n = 944; 35.6%) were the most common category used, while intravenous electrolytes (n = 341; 12.9%) and opioid analgesics (n = 248; 9.4%).were the most frequently used medications. Most commonly, medications were sourced from ward stocks. High blood pressure, heart or respiratory rate, pain, and multiple activation criteria were associated with MET medication use (p < 0.001). Patients who required medications were less likely to remain on the ward, and immediate admission to the ICU was approximately doubled (odds ratio = 1.90; 95% confidence interval = 1.47-2.45). CONCLUSION Medication use by the MET was common and associated with escalation to intensive care. A wide variety of medications, principally from ward stocks, were used with some predictability based on activation criteria. Local system improvements have demonstrated that by focusing on common MET syndromes and medications, further investigation can refine and improve medication use and management systems for deteriorating patients.
Collapse
|
11
|
Ganju A, Kapitola K, Chalwin R. Modifications to predefined rapid response team calling criteria: prevalence, characteristics and associated outcomes. CRIT CARE RESUSC 2019; 21:32-38. [PMID: 30857510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Standardised rapid response team (RRT) calling criteria may not be applicable to all patients, and thus, modifications of these criteria may be reasonable to prevent unnecessary calls. Little data are available regarding the efficacy or safety of modifying RRT calling criteria; therefore, this study aimed to detail the prevalence and characteristics of modifications to RRT call triggers and explore their relationship with patient outcomes. DESIGN AND OUTCOME MEASURES A pilot retrospective cohort study within a convenience sample of patients attended by a hospital RRT between July and December 2014; rates of repeat RRT calling and in-hospital mortality were compared between patients with and without modifications to standard calling criteria. Secondary analyses examined four different types of modifications, narrowing or widening of existing physiological calling criteria, to observations without defined calling criteria, and others. All analyses were performed using multivariable regression. RESULTS During the study period, 673 patients had RRT calls, of whom 620 (91.2%) had data available for analysis. The majority of study patients (393; 63.4%) had modifications documented. Patients with modifications were more likely to have repeat RRT calls (odds ratio [OR], 2.86; 95% CI, 1.69-4.85) and experience in-hospital mortality (OR, 2.16; 95% CI, 1.31-3.57) versus patients without modifications. In the secondary analyses, although all classes of modification had higher rates of repeat calling, none reached statistical significance. Mortality was associated with having modifications that were more conservative than the standard calling criteria (adjusted OR, 2.81; 95% CI, 1.31-6.08). CONCLUSION Modifications to standard calling criteria were frequently made, but did not seem to prevent further RRT calls and were associated with increased mortality. These findings suggest that modifications should be made with caution.
Collapse
Affiliation(s)
- Anamika Ganju
- Intensive Care Unit, Prince Charles Hospital, Brisbane, QLD, Australia.
| | - Karoline Kapitola
- Rapid Response System, Lyell McEwin Hospital, Elizabeth Vale, SA, Australia
| | - Richard Chalwin
- Rapid Response System, Lyell McEwin Hospital, Elizabeth Vale, SA, Australia
| |
Collapse
|
12
|
Kwack WG, Yun M, Lee DS, Min H, Choi YY, Lim SY, Kim Y, Lee SH, Lee YJ, Park JS, Cho YJ. Effectiveness of intrahospital transportation of mechanically ventilated patients in medical intensive care unit by the rapid response team: A cohort study. Medicine (Baltimore) 2018; 97:e13490. [PMID: 30508979 PMCID: PMC6283106 DOI: 10.1097/md.0000000000013490] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Critically ill patients could experience various risks including life-threatening events during intrahospital transportation (IHT), with a global incidence of 20% to 79.8%. Evidence on the clinical benefits of the presence of specialized intensive care members such as the rapid response team (RRT) during their transportation is limited. We aimed to elucidate the RRT's effectiveness in promoting patient's safety outcomes during transportation by comparing with those transport by general members.A single-center retrospective cohort study was conducted from January 2016 to February 2017, including critically ill patients admitted to the medical intensive care unit (ICU) due to respiratory failure under mechanical ventilation. Patients who underwent out-of-ICU transportation supported by RRT members, including a portable ventilator, were categorized as the RRT group, whereas those transported by general members, such as residents or interns, were the general group. Propensity score matching (PSM) was conducted due to several significant differences in the baseline characteristics between the 2 groups. Adverse events were defined as any situation requiring cardiopulmonary resuscitation (CPR), any physiologic deteriorations requiring immediate intervention or equipment dysfunctions.The median age of the 184 subjects included was 72 (inter quartile range, 62-75) years, and 114 (62.3%) of them were male. Thirty-six (19.6%) transports were supported by RRT, with significant higher APACHE II score than general groups (36.7 ± 6.0 vs 32.4 ± 7.7, P = .002). There was no critical event requiring CPR in both groups. However, adverse events were more frequently observed in the RRT than the general group (27.8% vs 8.1%, P = .001). PSM revealed insignificant difference in adverse events (26.7% vs 10.0%, P = .228).In critically ill patients in the medical ICU, IHT supported by the RRT did not show a more preventative effect on adverse events than that by the general group.
Collapse
Affiliation(s)
- Won Gun Kwack
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine
- Rapid Response Team, Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-Do, Republic of Korea
| | - Miae Yun
- Rapid Response Team, Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-Do, Republic of Korea
| | - Dong Seon Lee
- Rapid Response Team, Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-Do, Republic of Korea
| | - Hyunju Min
- Rapid Response Team, Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-Do, Republic of Korea
| | - Yun Young Choi
- Rapid Response Team, Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-Do, Republic of Korea
| | - Sung Yoon Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine
- Rapid Response Team, Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-Do, Republic of Korea
| | - Youlim Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine
- Rapid Response Team, Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-Do, Republic of Korea
| | - Sang Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine
- Rapid Response Team, Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-Do, Republic of Korea
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine
- Rapid Response Team, Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-Do, Republic of Korea
| |
Collapse
|
13
|
Chong-Yik R, Bennett AL, Milani RV, Morin DP. Cost-Saving Opportunities with Appropriate Utilization of Cardiac Telemetry. Am J Cardiol 2018; 122:1570-1573. [PMID: 30193738 DOI: 10.1016/j.amjcard.2018.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/13/2018] [Accepted: 07/17/2018] [Indexed: 11/17/2022]
Abstract
A third of healthcare spending in the United States is considered waste, and costs are growing at an unsustainable rate. Reducing unnecessary cardiac telemetry, a costly intervention with a high potential for overuse, may be an opportunity to reduce waste. We performed a review of 250 consecutive patients admitted to telemetry capable beds on the general medical-surgical, noncritical care units. Based on the American Heart Association Practice Standards for Electrocardiographic Monitoring in Hospital Settings, appropriateness of telemetric monitoring during each inpatient day was assessed, with identification of significant new arrhythmias, code calls, and clinical decisions resulting from telemetry. Cost of a telemetry day was calculated using a time-driven activity-based cost model. Patients (63 ± 19 years, 54% male) spent a total of 1,640 days hospitalized, 1,399 (85%) of which were on telemetry. Average length of stay was 6.6 days, and average telemetry time was 5.6 days. Only 334 (24%) telemetry days were deemed appropriate based on Practice Standards. During telemetric monitoring, 16 new significant arrhythmias were detected, 4 code calls were made, and 19 significant clinical decisions were prompted by telemetry. No cardiac code call occurred on a nontelemetry day. The cost of telemetry was calculated as $34.28 more per day than a nontelemetry hospital day. Elimination of inappropriate telemetry days would result in a minimum estimated savings of $37,007 in these 250 patients, and an annual savings of $528,241 overall. Telemetric monitoring is frequently overused. In conclusion, our findings propose that a reduction in inappropriate telemetry days in accordance with the American Heart Association Practice Standards could result in significant cost savings.
Collapse
Affiliation(s)
- Ronald Chong-Yik
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, Louisiana; Ochsner Clinical School, University of Queensland School of Medicine, Louisiana
| | - Amanda L Bennett
- Department of Cardiology, University of Rochester, Rochester, New York
| | - Richard V Milani
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, Louisiana; Ochsner Clinical School, University of Queensland School of Medicine, Louisiana
| | - Daniel P Morin
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, Louisiana; Ochsner Clinical School, University of Queensland School of Medicine, Louisiana.
| |
Collapse
|
14
|
Krowl L, Gudlavalleti A, Patel A, Panebianco L, Kosters M, Dhamoon AS. A pilot study to standardize and peer-review shift handoffs in an academic internal medicine residency program: The DOCFISH method. Medicine (Baltimore) 2018; 97:e12798. [PMID: 30313109 PMCID: PMC6203497 DOI: 10.1097/md.0000000000012798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
With increased oversight of residency work hours, there has been an increase in shift handoffs, which are prone to medical errors. To date, there are no evidence-based recommendations on essential elements of shift handoffs. We implemented a standardized shift-handoff rubric at an academic medicine residency program. Compliance, resident/faculty perceptions, and surrogate markers of patient safety were measured.Shift-handoff documents were collected January-February 2016 (control) April-June 2016 (intervention). Signouts were scored based on inclusion of seven elements: Daily events, Overnight events, Code status, Follow up tasks, If/then statements, 'sick or stable' and History present illness. The mnemonic 'DOCFISH' was taught in a grand-rounds forum then embedded into a shift-handoff tool within our electronic health record (EHR). Senior residents were assigned to supervise/provide feedback on shift handoffs from April-June 2016. Faculty and resident perceptions regarding quality of shift handoffs was measured by the annual ACGME (Accreditation Council Graduate Medical Education) program survey.Patient safety was measured by number of rapid-response teams (RRT) initiated for unstable vital signs. Handoffs were 74% complete in intervention group and 60% in control group (p < .0001). Median DOCFISH features present in patients that required RRT was 3 of 7 whereas, total post-intervention group had 5 of 7 (p < .001). 'Daily events' and 'follow -up tasks' were less frequent in patients that required RRT (20%, 67% respectively, p < .001).Academic medical centers can implement standardized shift handoffs by embedding high-yield information in an EHR with peer-review. Information during shift changes that may have significant improvement on patient safety includes: 'daily events' and 'follow -up tasks.'
Collapse
Affiliation(s)
- Lauren Krowl
- Chief Medicine Resident Quality and Patient Safety, State University of New York (SUNY) Upstate Medical University, Syracuse, New York
| | - Aashrai Gudlavalleti
- Chief Neurology Resident Quality and Patient Safety, State University of New York (SUNY) Upstate Medical University, Syracuse, New York
| | - Arpan Patel
- Hematology/Oncology Fellow, University of Florida, Gainesville, Florida
| | - Lauren Panebianco
- Hematology/Oncology Fellow, State University of New York (SUNY) Upstate Medical University, Syracuse, New York
| | - Michael Kosters
- Pulmonary/Critical Care Fellow, State University of New York (SUNY) Upstate Medical University, Syracuse, New York
| | - Amit S. Dhamoon
- Assistant Professor of Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, New York, USA
| |
Collapse
|
15
|
LeGuen M, Ballueer Y, McKay R, Eastwood G, Bellomo R, Jones D. Frequency and significance of qSOFA criteria during adult rapid response team reviews: A prospective cohort study. Resuscitation 2017; 122:13-18. [PMID: 29133019 DOI: 10.1016/j.resuscitation.2017.11.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/24/2017] [Accepted: 11/09/2017] [Indexed: 11/19/2022]
Abstract
AIM A new definition of sepsis released by an international task-force has introduced the concept of quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA). This study aimed to measure the proportion of patients who fulfilled qSOFA criteria during a Rapid Response Team (RRT) review and to assess their associated outcomes. METHODS We conducted a prospective study of adult RRT reviews over a one month period between 6th June and 10th July 2016 in a large tertiary hospital in Melbourne Australia RESULTS: Over a one-month period, there were 282 RRT reviews, 258 of which were included. One hundred out of 258 (38.8%) RRT review patients fulfilled qSOFA criteria. qSOFA positive patients were more likely to be admitted to the intensive care unit (29% vs 18%, P=0.04), to have repeat RRT reviews (27% vs 13%; p=0.007) and die in hospital (31% vs 10%, P<0.001). qSOFA positive patients with suspected infection were more likely to be admitted to the intensive care unit compared to patients with infection alone (37% vs 15%, P=0.002). Eleven of 42 patients (26%) who had infection and qSOFA died whilst in hospital, compared to 8/55 (15%) of patients with infection alone (P=0.2). CONCLUSION Adult patients who are qSOFA positive at the time of their RRT review are at increased risk of in-hospital mortality. The assessment of qSOFA may be a useful triage tool during a RRT review.
Collapse
Affiliation(s)
- Maurice LeGuen
- Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, 3004, Australia
| | - Yvonne Ballueer
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
| | - Richard McKay
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
| | - Daryl Jones
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| |
Collapse
|
16
|
Abstract
Rapid response team (RRT) adoption and implementation are associated with improved quality of care of patients who experience an unanticipated medical emergency. The sustainability of RRTs is vital to achieve long-term benefits of these teams for patients, staff, and hospitals. Factors required to achieve RRT sustainability remain unclear. This study examined the relationship between sustainability elements and RRT sustainability in hospitals that have previously implemented RRTs.
Collapse
|
17
|
Parrish WM, Hravnak M, Dudjak L, Guttendorf J. Impact of a Modified Early Warning Score on Rapid Response and Cardiopulmonary Arrest Calls in Telemetry and Medical-Surgical Units. Medsurg Nurs 2017; 26:15-19. [PMID: 30351569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
To reduce the number of cardiac arrests in telemetry and medical- surgical units, a 70-bed community hospital integrated a weighted, aggregate, electronic modified early warning score into the elec- tronic medical record. Impact was evaluated via a quality improvement initiative.
Collapse
|
18
|
Joint College of Intensive Care Medicine and Australian and New Zealand Intensive Care Society Special Interest Group on Rapid Response Systems, ANZICS Centre for Outcome and Resource Evaluation. Resource use, governance and case load of rapid response teams in Australia and New Zealand in 2014. CRIT CARE RESUSC 2016; 18:275-82. [PMID: 27903210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Rapid response teams (RRTs) are a mandatory element of Australian national health care policy. However, the uptake, resourcing, case load and funding of RRTs in Australian and New Zealand hospitals remain unknown. AIM To assess the clinical activity, funding, staffing and governance of RRTs in Australian and New Zealand hospitals. METHODS Survey of Australian and New Zealand hospitals as part of a biannual audit of intensive care resources and capacity. RESULTS Of 207 hospitals surveyed, 165 (79.7%) participated, including 22 (13.3%) from New Zealand. RRTs were present in 138/143 (95.5%) Australian and 11/22 (50%) New Zealand hospitals equipped with intensive care units (P < 0.001). Additional funding was provided in 43/146 hospitals (29.4%) but was more likely in tertiary ICUs (P < 0.001) and in New Zealand (P = 0.012). ICU staff participated in 147/148 RRTs (99.3%), which involved medical staff only (10.2%), nursing staff only (6.8%), and both medical and nursing staff (76.2%). Isolated ICU nursing involvement was more common in smaller ICUs (P = 0.005), in rural/regional and metropolitan hospitals (P = 0.04), and in New Zealand (P = 0.006). Dedicated ICU outreach registrars and consultants were present in 19/146 hospitals (13.0%) and 14/145 hospitals (9.7%), respectively. The ICU provided oversight for 122/147 RRTs (83%). In the 2013-14 financial year, there were more than 104 000 RRT calls. CONCLUSION In cases where data were known, ICU staff provided staff for most RRTs, and oversight for more than 80% of RRTs. However, additional funding for ICU RRT staff and dedicated doctors was relatively uncommon.
Collapse
|
19
|
Escobar GJ, Turk BJ, Ragins A, Ha J, Hoberman B, LeVine SM, Ballesca MA, Liu V, Kipnis P. Piloting electronic medical record-based early detection of inpatient deterioration in community hospitals. J Hosp Med 2016; 11 Suppl 1:S18-S24. [PMID: 27805795 PMCID: PMC5510649 DOI: 10.1002/jhm.2652] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 08/15/2016] [Accepted: 08/24/2016] [Indexed: 11/12/2022]
Abstract
Patients who deteriorate in the hospital outside the intensive care unit (ICU) have higher mortality and morbidity than those admitted directly to the ICU. As more hospitals deploy comprehensive inpatient electronic medical records (EMRs), attempts to support rapid response teams with automated early detection systems are becoming more frequent. We aimed to describe some of the technical and operational challenges involved in the deployment of an early detection system. This 2-hospital pilot, set within an integrated healthcare delivery system with 21 hospitals, had 2 objectives. First, it aimed to demonstrate that severity scores and probability estimates could be provided to hospitalists in real time. Second, it aimed to surface issues that would need to be addressed so that deployment of the early warning system could occur in all remaining hospitals. To achieve these objectives, we first established a rationale for the development of an early detection system through the analysis of risk-adjusted outcomes. We then demonstrated that EMR data could be employed to predict deteriorations. After addressing specific organizational mandates (eg, defining the clinical response to a probability estimate), we instantiated a set of equations into a Java application that transmits scores and probability estimates so that they are visible in a commercially available EMR every 6 hours. The pilot has been successful and deployment to the remaining hospitals has begun. Journal of Hospital Medicine 2016;11:S18-S24. © 2016 Society of Hospital Medicine.
Collapse
Affiliation(s)
- Gabriel J Escobar
- Division of Research, Kaiser Permanente Northern California, Oakland, California. , , , ,
- Department of Inpatient Pediatrics, Kaiser Permanente Medical Center, Walnut Creek, California. , , , ,
| | - Benjamin J Turk
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Arona Ragins
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jason Ha
- IMG-Systems Integration, Kaiser Permanente, Pleasanton, California
| | | | | | | | - Vincent Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California
- Department of Critical Care, Kaiser Permanente Medical Center, Santa Clara, California
| | - Patricia Kipnis
- Decision Support, Kaiser Foundation Health Plan, Oakland, California
| |
Collapse
|
20
|
Solomon RS, Corwin GS, Barclay DC, Quddusi SF, Dannenberg MD. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: A systematic review and meta-analysis. J Hosp Med 2016; 11:438-45. [PMID: 26828644 DOI: 10.1002/jhm.2554] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/24/2015] [Accepted: 01/05/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND In 2004, the Institute for Healthcare Improvement's 100,000 Lives Campaign recommended that hospitals implement rapid response teams (RRTs) charged with identifying non-intensive care unit (ICU) patients at risk for rapid deterioration. Although RRTs are now in widespread use, there have been conflicting results regarding the impact of RRTs on hospital mortality and cardiopulmonary arrest. PURPOSE To assess the effectiveness of RRTs on reducing hospital mortality and non-ICU cardiopulmonary arrest rates. DATA SOURCES We conducted a systematic review using MEDLINE (1966-2014), Cochrane Central Register of Controlled Trials (1898-2014), Cumulative Index to Nursing and Allied Health Literature (1994-2014), and ClinicalTrials.gov (1997-2014) during October 2014. There were no constraints on language or publication status. DATA EXTRACTION We included before-after studies, cohort studies, and cluster randomized trials that reported hospital mortality and/or non-ICU cardiopulmonary arrest for adults hospitalized in a non-ICU setting after the implementation of RRTs and/or medical emergency teams (METs). Data were extracted by 2 sets of 2 independent reviewers using a standardized data-collection form. Disagreements were resolved by a third reviewer. Authors were contacted to obtain any missing data. DATA SYNTHESIS Our search identified 691 studies, of which 30 met criteria for inclusion in the analysis. Implementation of an RRT/MET was associated with a significant decrease in hospital mortality (relative risk [RR] = 0.88, 95% confidence interval [CI]: 0.83-0.93, I(2) = 86%, 3,478,952 admissions) and a significant decrease in the number of non-ICU cardiac arrests (RR = 0.62, 95% CI: 0.55-0.69, I(2) = 71%, 3,045,273 admissions). CONCLUSIONS Implementation of an RRT/MET is associated with a reduction in both hospital mortality and non-ICU cardiopulmonary arrests. Journal of Hospital Medicine 2016;11:438-445. © 2016 Society of Hospital Medicine.
Collapse
Affiliation(s)
- Rose S Solomon
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Gregory S Corwin
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Dawn C Barclay
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Sarah F Quddusi
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Michelle D Dannenberg
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| |
Collapse
|
21
|
Sharma S, Chowdhury A, Tang L, Willes L, Glynn B, Quan SF. Hospitalized Patients at High Risk for Obstructive Sleep Apnea Have More Rapid Response System Events and Intervention Is Associated with Reduced Events. PLoS One 2016; 11:e0153790. [PMID: 27168330 PMCID: PMC4864239 DOI: 10.1371/journal.pone.0153790] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 04/04/2016] [Indexed: 01/09/2023] Open
Abstract
Background Rapid response system (RRS) is a safety tool designed for early detection and intervention of a deteriorating patient on the general floor in the hospital. Obstructive sleep apnea (OSA) has been associated with significant cardiovascular complications. We hypothesized that patients with high-risk of OSA have higher rate of RRS events and intervention with positive airway pressure therapy in these patients can mitigate the RRS events. Methods As part of a clinical pathway, during a 15 month period, patients with BMI ≥ 30 kg/m2 in select medical services were screened with a validated sleep questionnaire. Patients were characterized as high or low risk based on the screening questionnaire. RRS rates were compared between the groups. Subsequently the impact of PAP therapy on RRS events was evaluated. Results Out of the 2,590 patients screened, 1,973 (76%) were identified as high-risk. RRS rates calculated per 1,000 admissions, were 43.60 in the High-Risk OSA group versus 25.91 in the Low-Risk OSA Group. The PAP therapy compliant group had significantly reduced RRS event rates compared to non-compliant group and group with no PAP therapy (16.99 vs. 53.40 vs. 56.21) (p < 0.01). Conclusion In a large cohort of patients at a tertiary care hospital, we show an association of increased rate of RRS events in high-risk OSA patients and reduction of the risk with PAP intervention in the compliant group.
Collapse
Affiliation(s)
- Sunil Sharma
- Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Anindita Chowdhury
- Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Lili Tang
- Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Leslee Willes
- Willes Consulting Group Inc., Encinitas, California, United States of America
| | - Brian Glynn
- Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Stuart F. Quan
- Harvard Medical School, Boston, Massachusetts, United States of America
- University of Arizona College of Medicine, Tucson, Arizona, United States of America
| |
Collapse
|
22
|
Cabrini L, Giannini A, Pintaudi M, Semeraro F, Radeschi G, Borga S, Landoni G, Troiano H, Luchetti M, Pellis T, Ristagno G, Minoja G, Mazzon D, Alampi D. Ethical issues associated with in-hospital emergency from the Medical Emergency Team's perspective: a national survey. Minerva Anestesiol 2016; 82:50-57. [PMID: 26044935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Medical Emergency Teams (METs) are frequently involved in ethical issues associated to in-hospital emergencies, like decisions about end-of-life care and intensive care unit (ICU) admission. MET involvement offers both advantages and disadvantages, especially when an immediate decision must be made. We performed a survey among Italian intensivists/anesthesiologists evaluating MET's perspective on the most relevant ethical aspects faced in daily practice. METHODS A questionnaire was developed on behalf of the Italian scientific society of anesthesia and intensive care (SIAARTI) and administered to its members. Decision making criteria applied by respondents when dealing with ethical aspects, the estimated incidence of conflicts due to ethical issues and the impact on the respondents' emotional and moral distress were explored. RESULTS The questionnaire was completed by 327 intensivists/anesthesiologists. Patient life-expectancy, wishes, and the quality of life were the factors most considered for decisions. Conflicts with ward physicians were reported by most respondents; disagreement on appropriateness of ICU admission and family unpreparedness to the imminent patient death were the most frequent reasons. Half of respondents considered that in case of conflicts the final decision should be made by the MET. Conflicts were generally recognized as causing increased and moral distress within the MET members. Few respondents reported that dedicated protocols or training were locally available. CONCLUSION Italian intensivists/anesthesiologists reported that ethical issues associated with in-hospital emergencies are occurring commonly and are having a significant negative impact on MET well-being. Conflicts with ward physicians happen frequently. They also conveyed that hospitals don't offer ethics training and have no protocols in place to address ethical issues.
Collapse
Affiliation(s)
- Luca Cabrini
- Anesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy -
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Considine J, Jones D, Pilcher D, Currey J. Physiological status during emergency department care: relationship with inhospital death after clinical deterioration. CRIT CARE RESUSC 2015; 17:257-262. [PMID: 26640061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To examine the relationship between patient physiological status in the emergency department (ED) and inhospital mortality after rapid response team (RRT) or cardiac arrest team (CAT) activations within 72 hours of emergency admission to medical or surgical wards. DESIGN, SETTING AND PARTICIPANTS A multisite, retrospective, cohort study of 660 randomly selected (220 patients per site) adult medical or surgical patients who were admitted from the ED during 2012 and who had had an RRT or CAT activation within 72 hours of admission, at three hospitals in Melbourne, Australia. MAIN OUTCOME MEASURE Inhospital mortality. RESULTS There were 825 RRT activations (for 634 patients) and 42 CAT activations (for 35 patients). The median time to the first RRT or CAT activation was 18.8 hours and was significantly shorter in patients who died in hospital (14.6 v 20.6 hours, P=0.036). Compared with survivors, patients who died were more likely to have at least one observation meeting RRT criteria during their ED stay (45.9% v 34.8%; P=0.029): tachypnoea (21.1% v 13.4%, P=0.039), hypotension (20.2% v 11.8%, P=0.018), hypoxaemia (8.3% v 3.1%, P=0.001) and altered conscious state (6.2% v 1.3%, P=0.001) were more common in patients who died. The risk-adjusted odds ratio (OR) for inhospital death was highest for patients with an altered conscious state during their ED stay (OR, 4.633; 95% CI, 1.365-15.728; P=0.014). CONCLUSIONS In patients who needed an RRT or CAT activation within the first 72 hours of emergency admission to medical or surgical wards, there was a strong association between physiological derangement during ED care and inhospital death.
Collapse
Affiliation(s)
| | | | | | - Judy Currey
- Deakin University, Melbourne, VIC, Australia
| |
Collapse
|
24
|
Davis DP, Aguilar SA, Graham PG, Lawrence B, Sell RE, Minokadeh A, Husa RD. A novel configuration of a traditional rapid response team decreases non-intensive care unit arrests and overall hospital mortality. J Hosp Med 2015; 10:352-7. [PMID: 25772392 DOI: 10.1002/jhm.2338] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 12/12/2014] [Accepted: 12/21/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND In-hospital cardiopulmonary arrest (CPA) accounts for substantial morbidity and mortality. Rapid response teams (RRTs) are designed to prevent non-intensive care unit (ICU) CPA through early detection and intervention. However, existing evidence has not consistently demonstrated a clear benefit. OBJECTIVE To explore the effectiveness of a novel RRT program design to decrease non-ICU CPA and overall hospital mortality. METHODS This study was conducted from the start of fiscal year 2005 to 2011. In November 2007, our hospitals implemented RRTs as part of a novel resuscitation program. Charge nurses from each inpatient unit underwent training as unit-specific RRT members. Additionally, all inpatient staff received annual training in RRT concepts including surveillance and recognition of deterioration. We compared the incidence of ICU and non-ICU CPA from first complete preimplementation year 2006 to postimplementation years 2007 to 2011. Overall hospital mortality was also reported. RESULTS The incidence of non-ICU CPA decreased, whereas the incidence of ICU CPA remained unchanged. Overall hospital mortality also decreased (2.12% to 1.74%, P < 0.001). The year-over-year change in RRT activations was inversely related to the change in Code Blue activations for each inpatient unit (r = -0.68, P < 0.001). CONCLUSION Our novel RRT program was associated with a decreased incidence of non-ICU CPA and improved hospital mortality.
Collapse
Affiliation(s)
- Daniel P Davis
- Department of Emergency Medicine, University of California-San Diego, San Diego, California
| | - Steve A Aguilar
- Department of Emergency Medicine, University of California-San Diego, San Diego, California
| | - Patricia G Graham
- Department of Nursing Education, Development, Research, University of California-San Diego, San Diego, California
| | - Brenna Lawrence
- Department of Nursing, University of California-San Diego, San Diego, California
| | - Rebecca E Sell
- Division of Pulmonary and Critical Care Medicine, University of California-San Diego, San Diego, California
| | - Anushirvan Minokadeh
- Department of Anesthesiology, University of California-San Diego, San Diego, California
| | - Ruchika D Husa
- Division of Cardiology, University of California-San Diego, San Diego, California, and the Division of Cardiology, The Ohio State University, Columbus, Ohio
| |
Collapse
|
25
|
Zipkin R, Ostrom K, Olowoyeye A, Markovitz B, Schrager SM. Association Between Implementation of a Cardiovascular Step-Down Unit and Process-of-Care Outcomes in Patients With Congenital Heart Disease. Hosp Pediatr 2015; 5:256-262. [PMID: 25934809 DOI: 10.1542/hpeds.2014-0046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The Joint Commission's 2009 National Patient Safety Goals aimed to improve identification of and response to clinical deterioration in hospital-ward patients. Some hospitals implemented intermediate-care units for patients without intensive care-level support needs. No studies have evaluated what effect changes associated with a move to a pediatric cardiovascular step-down unit (CVSDU) has on process-of-care outcomes. METHODS A retrospective cohort study comparing process-of-care outcomes in units caring for children with congenital heart disease (n=1415) 1 year before (July 1, 2010-June 30, 2011) and 1 year after (August 1, 2011-July 30, 2012) implementation of a CVSDU following the move to a new hospital building. Units caring for noncardiac tracheostomy and/or ventilator-dependent patients were used as controls (n=606). Primary outcomes included length of stay (LOS) and transfers to higher levels of care. Secondary outcomes included rapid response team, cardiopulmonary arrest, and code blue rates. Mann-Whitney U and z tests were used for all analyses. RESULTS When compared with a medical-surgical unit, cardiac patients admitted to a CVSDU had a significantly decreased total LOS (median 7.0 vs 5.4 days, P=.03), non-ICU LOS (median 3.5 vs 3.0 days, P=.006), and rapid response team/code blue rate per 1000 non-ICU patient days (11.2 vs 7.0, P=.04). No significant differences in primary or secondary outcomes were seen within the control group. CONCLUSIONS Changes associated with a new CVSDU were associated with decreased LOS and lower rates of rapid response and code blue events for patients with congenital heart disease.
Collapse
Affiliation(s)
- Ronen Zipkin
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Kathleen Ostrom
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Abiola Olowoyeye
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Barry Markovitz
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Sheree M Schrager
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
| |
Collapse
|
26
|
Abstract
BACKGROUND A subset of critically ill patients have end-of-life (EOL) goals that are unclear. Rapid response teams (RRTs) may aid in the identification of these patients and the delivery of their EOL care. OBJECTIVES To characterize the impact of RRT discussion on EOL care, and to examine how a preprinted order (PPO) set for EOL care influenced EOL discussions and outcomes. METHODS A single-centre retrospective chart review of all RRT calls (January 2009 to December 2010) was performed. The effect of RRT EOL discussions and the effect of a hospital-wide PPO set on EOL care was examined. Charts were from the Ontario Ministry of Health and Long-Term Care Critical Care Information Systemic database, and were interrogated by two reviewers. RESULTS In patients whose EOL status changed following RRT EOL discussion, there were fewer intensive care unit (ICU) transfers (8.4% versus 17%; P<0.001), decreased ICU length of stay (5.8 days versus 20 days; P=0.08), increased palliative care consultations (34% versus 5.3%; P<0.001) and an increased proportion who died within 24 h of consultation (25% versus 8.3%; P<0.001). More patients experienced a change in EOL status following the introduction of an EOL PPO, from 20% (before) to 31% (after) (P<0.05). CONCLUSIONS A change in EOL status following RRT-led EOL discussion was associated with reduced ICU transfers and enhanced access to palliative care services. Further study is required to identify and deconstruct barriers impairing timely and appropriate EOL discussions.
Collapse
Affiliation(s)
- Benjamin Tam
- Department of Medicine, Division of General Internal Medicine, McMaster University, Hamilton, Ontario
| | - Mary Salib
- Department of Medicine, Division of General Internal Medicine, McMaster University, Hamilton, Ontario
| | - Alison Fox-Robichaud
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, Ontario
| |
Collapse
|
27
|
Roberts KE, Bonafide CP, Paine CW, Paciotti B, Tibbetts KM, Keren R, Barg FK, Holmes JH. Barriers to calling for urgent assistance despite a comprehensive pediatric rapid response system. Am J Crit Care 2014; 23:223-9. [PMID: 24786810 DOI: 10.4037/ajcc2014594] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Rapid response systems (RRSs) aim to identify and rescue hospitalized patients whose condition is deteriorating before respiratory or cardiac arrest occurs. Previous studies of RRS implementation have shown variable effectiveness, which may be attributable in part to barriers preventing staff from activating the system. OBJECTIVE To proactively identify barriers to calling for urgent assistance that exist despite recent implementation of a comprehensive RRS in a children's hospital. METHODS Qualitative study using open-ended, semistructured interviews of 27 nurses and 30 physicians caring for patients in general medical and surgical care areas. RESULTS The following themes emerged: (1) Self-efficacy in recognizing deteriorating conditions and activating the medical emergency team (MET) were considered strong determinants of whether care would be appropriately escalated for children in a deteriorating condition. (2) Intraprofessional and interprofessional hierarchies were sometimes challenging to navigate and led to delays in care for patients whose condition was deteriorating. (3) Expectations of adverse interpersonal or clinical outcomes from MET activations and intensive care unit transfers could strongly shape escalation-of-care behavior (eg, reluctance among subspecialty attending physicians to transfer patients to the intensive care unit for fear of inappropriate management). CONCLUSIONS The results of this study provide an in-depth description of the barriers that may limit RRS effectiveness. By recognizing and addressing these barriers, hospital leaders may be able to improve the RRS safety culture and thus enhance the impact of the RRS on rates of cardiac arrest, respiratory arrest, and mortality outside the intensive care unit.
Collapse
Affiliation(s)
- Kathryn E Roberts
- Kathryn E. Roberts is a clinical nurse specialist in the Department of Nursing, The Children's Hospital of Philadelphia, Pennsylvania. Christopher P. Bonafide is an assistant professor of pediatrics in the Division of General Pediatrics at The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. Christine Weirich Paine is a senior clinical research assistant in the Division of General Pediatrics, The Children's Hospital of Philadelphia. Breah Paciotti is a senior research coordinator in the Mixed Methods Research Lab, University of Pennsylvania. Kathleen M. Tibbetts was a graduate research assistant in the Division of General Pediatrics, The Children's Hospital of Philadelphia at the time of this work and is now a senior research associate at GfK Healthcare, Blue Bell, Pennsylvania. Ron Keren is a professor of pediatrics and epidemiology at the Perelman School of Medicine at the University of Pennsylvania and an attending physician in the Division of General Pediatrics and chief quality officer at The Children's Hospital of Philadelphia. Frances K. Barg is an associate professor of family medicine and community health at the Perelman School of Medicine and an associate professor in the Department of Anthropology in the School of Arts and Sciences at the University of Pennsylvania. John H. Holmes is an associate professor of medical informatics in epidemiology, chair of the Graduate Group in Epidemiology and Biostatistics, and associate director of the Institute for Biomedical Informatics at the University of Pennsylvania Perelman School of Medicine
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Guła P, Wejnarski A, Moryto R, Gałazkowski R, Swiezewski S. [Analysis of actions taken by medical rescue teams in the Polish Emergency Medical Servies system. Is the model of division into specialistad basic teams reasonable?]. Wiad Lek 2014; 67:468-475. [PMID: 26030950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The Polish Emergency Medical Services (EMS) system is based on two types of medical rescue teams (MRT): specialist (S)--with system doctors and basic (B)--only paramedics. AIM OF THE STUDY The aim of this study is to assess the reasonability of dividing medical rescue teams into specialist and basic. MATERIAL AND METHODS The retrospective analysis of medical cards of rescue activities performed during 21,896 interventions by medical rescue teams, 15,877 of which--by basic medical rescue teams (B MRT) and 6,019--by specialist medical rescue teams (S MRT). The procedures executed by both types of teams were compared. RESULTS In the analysed group of dispatches, 56.4% were unrelated to medical emergencies. Simultaneously, 52.7% of code 1 interventions and 59.2% of code 2 interventions did not result in transporting the patient to the hospital. The qualification of S teams' dispatches is characterised by a higher number of assigned codes 1 (53.2% vs. 15.9%). It is worth emphasising that the procedures that can be applied exclusively by system doctors do not exceed 1% of interventions. Moreover, the number of the actions performed in medical emergencies in the secured region by the S team that is dispatched as the first one is comparable to that performed by B teams. The low need for usinq S teams'aid by B teams (0.92% of the interventions) was also indicated. CONCLUSIONS This study points to the necessity to discuss the implementation of straightforward principles of call qualification and the optimisation of the system doctors' role in prehospital activities.
Collapse
|
29
|
ANZICS-CORE MET dose investigators. Mortality of rapid response team patients in Australia: a multicentre study. CRIT CARE RESUSC 2013; 15:273-8. [PMID: 24289508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Most studies of the rapid response team (RRT) investigate the effect of introducing an RRT on outcomes of all hospitalised patients. Less information exists on RRT patient epidemiology, or changes in RRT call numbers with time. OBJECTIVES To estimate the inhospital mortality of patients subject to RRT review, the proportion of inhospital deaths reviewed by the RRT, and changes in annual RRT call numbers with time. METHOD Retrospective observational study in adult RRT equipped Australian hospitals for up to 10 years (2000-2009). PARTICIPANTS AND OUTCOME MEASURES Thirty-four per cent (35/102) of the Australian adult RRT-equipped hospitals provided annual hospital admissions and deaths, intensive care unit admissions and RRT calls. They also provided the number of patients reviewed by the RRT and the number of inhospital deaths in such patients. RESULTS Over the study period, there were 4.91 million hospital admissions, 196 488 ICU admissions and 99 377 RRT calls. Most data arose from Victoria, New South Wales and Western Australia, and from public tertiary hospitals. Among the 27 hospitals contributing at least 4 years of data, annual RRT calls per 1000 admissions was higher in the last year compared with the first year of data submission in 23 hospitals (range of increase, 11.9%- 777.4%; median, 90%; interquartile range, 40%-180%). In the remaining four hospitals, annual RRT calls per 1000 admissions were lower in the last year compared with the first year (range of decrease, - 5.5% to - 29.8%). Among the 70 924 RRT patients for whom the outcome was known, there were 17 260 deaths (24.3%). We calculate that the RRT reviewed 17 260 of 79 476 patients (21.7%) who died in hospital over the study period. In the 2008-09 financial year, there were 18 800 RRT calls for at least 14 743 patients. CONCLUSIONS Annual RRT calls are increasing in many Australian hospitals, and now affect more than 14 700 patients annually. Inhospital mortality of RRT patients is about 25%, and about 20% of patients who die in hospital are reviewed by the RRT. Further research is needed to understand the reason for the high inhospital mortality of RRT patients.
Collapse
|
30
|
Abstract
The authors collected data on diagnosis, hospital course, and end-of life preparedness in patients who died in the intensive care unit (ICU) with '"full code" status (defined as receiving cardiopulmonary resuscitation), compared with those who didn't. Differences were analyzed using binary and stepwise logistic regression. They found no differences in demographics, comorbidities, ventilator, hospital, or ICU days between groups. No-code patients were more likely to have higher APACHE-II scores (p < .0001), gastrointestinal/hepatic conditions (p < .01) and an advanced directive (p = .03). Patients dying with full code status were more likely to have previously coded (p < .0001), and had more central lines (p = .03). Implications are discussed.
Collapse
Affiliation(s)
- Lauren Jodi Van Scoy
- Department of Internal Medicine and Division of Pulmonary, Critical Care and Sleep Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania 19102, USA.
| | - Michael Sherman
- Department of Internal Medicine and Division of Pulmonary, Critical Care and Sleep Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania 19102, USA
| |
Collapse
|
31
|
Smith GB, DeVita MA. In reference to impact of proactive rounding by a rapid response team on patient outcomes at an academic medical center. J Hosp Med 2013; 8:282. [PMID: 23606328 DOI: 10.1002/jhm.2040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 02/14/2013] [Indexed: 11/10/2022]
|
32
|
Auerbach A. Response to DeVita. J Hosp Med 2013; 8:283. [PMID: 23606311 DOI: 10.1002/jhm.2039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 02/15/2013] [Indexed: 11/05/2022]
|
33
|
Medical Emergency Team End-of-Life Care investigators. The timing of Rapid-Response Team activations: a multicentre international study. CRIT CARE RESUSC 2013; 15:15-20. [PMID: 23432496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Most studies of Rapid-Response Teams (RRTs) assess their effect on outcomes of all hospitalised patients. Little information exists on RRT activation patterns or why RRT calls are needed. Triage error may necessitate RRT review of ward patients shortly after hospital admission. RRT diurnal activation rates may reflect the likely frequency of caregiver visits. OBJECTIVES To study the timing of RRT calls in relation to time of day and day of week, and their frequency and outcomes in relation to days after hospital admission. METHODS We prospectively studied RRT calls over 1 month in seven hospitals during 2009, collecting data on patient age, sex, admitting unit, admission source, limitations of medical therapy (LOMTs), and admission and discharge dates. We assessed the timing of RRT calls in relation to hospital admission and circadian variation; and differences in characteristics and outcomes of calls occurring early (Days 0 and 1) versus late (after Day 7) after hospital admission. RESULTS There were 652 RRT calls for 518 patients. Calls were more likely on Mondays (P=0.018) and during work hours (P<0.0001) but less likely on weekends (P=0.003) or overnight (P<0.001). There were 177 early calls (27.1%) and 198 late calls (30.4%). Early calls involved younger patients (median ages, 67.5 years [early calls] v 73 years [late calls]; P= 0.01), fewer LOMTs (P=0.029), and lower in hospital mortality (12.8% [early calls] v 32.3% [late calls]; P<0.0001). The mortality difference remained in patients without LOMTs (5.6% [early calls] v 19.6% [late calls]; P=0.003). CONCLUSIONS About one-quarter of RRT calls occurred shortly after hospital admission, and were more common when caregivers were around. Early calls may partially reflect suboptimal triage, though the associated mortality appeared low. Late calls may reflect suboptimal end-of-life care planning, and the associated mortality was high. There is a need to further assess the epidemiology of RRT calls at different phases of the hospital stay.
Collapse
|
34
|
Frydshou A, Gillesberg I. [Medical emergency teams are activated less than expected]. Ugeskr Laeger 2013; 175:488-490. [PMID: 23428262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Medical emergency teams (MET) are established at several Danish hospitals. We report experiences from 2010-2011 at a university hospital with 73,360 admissions in 2011. MET is activated less than expected as a systematic track and trigger system is not implemented yet. The most common trigger of MET is respiratory problems. MET have an important role of limitations of therapy or do not resuscitate orders in patients with critical irreversible illness. One in five patients seen by MET were admitted to the intensive care unit. Currently the Capital Region of Denmark covering 12 hospitals is implementing a full rapid response system at all hospitals.
Collapse
|
35
|
Lund C. [Medical emergency teams and their success criteria]. Ugeskr Laeger 2013; 175:484. [PMID: 23428260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
|
36
|
Butcher BW, Vittinghoff E, Maselli J, Auerbach AD. Impact of proactive rounding by a rapid response team on patient outcomes at an academic medical center. J Hosp Med 2013; 8:7-12. [PMID: 23024019 PMCID: PMC3538927 DOI: 10.1002/jhm.1977] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 06/26/2012] [Accepted: 07/30/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND The impact of rapid response teams (RRT) on patient outcomes remains uncertain. OBJECTIVE To examine the effect of proactive rounding by an RRT on outcomes of hospitalized adults discharged from intensive care. DESIGN Retrospective, observational study. SETTING Academic medical center. PATIENTS All adult patients discharged alive from the intensive care unit (ICU) at the University of California San Francisco Medical Center between January 2006 and June 2009. INTERVENTION Introduction of proactive rounding by an RRT. MEASUREMENTS Outcomes included the ICU readmission rate, ICU average length of stay (LOS), and in-hospital mortality of patients discharged from the ICU. Data were obtained from administrative billing databases and analyzed using an interrupted time series (ITS) model. RESULTS We analyzed 17 months of preintervention data and 25 months of postintervention data. Introduction of proactive rounding by the RRT did not change the ICU readmission rate (6.7% before vs 7.3% after; P = 0.24), the ICU LOS (5.1 days vs 4.9 days; P = 0.24), or the in-hospital mortality of patients discharged from the ICU (6.0% vs 5.5%; P = 0.24). ITS models testing the impact of proactive rounding on secular trends found no improvement in any of the 3 clinical outcomes relative to their preintervention trends. CONCLUSIONS Proactive rounding by an RRT did not improve patient outcomes, raising further questions about RRT benefits.
Collapse
Affiliation(s)
- Brad W Butcher
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA.
| | | | | | | |
Collapse
|
37
|
Benin AL, Borgstrom CP, Jenq GY, Roumanis SA, Horwitz LI. Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators. BMJ Qual Saf 2012; 21:391-8. [PMID: 22389019 PMCID: PMC3423909 DOI: 10.1136/bmjqs-2011-000390] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital. METHODS We analysed 49 open-ended interviews with administrators, primary team attending physicians, trainees, RRT attending hospitalists, staff nurses, nurses and respiratory technicians. RESULTS Themes elicited were categorised into the domains of (1) morale and teamwork, (2) education, (3) workload, (4) patient care, and (5) hospital administration. Positive implications beyond improved care for acutely ill patients were: increased morale and empowerment among nurses, real-time redistribution of workload for nurses (reducing neglect of non-acutely ill patients during emergencies), and immediate access to expert help. Negative implications were: increased tensions between nurses and physician teams, a burden on hospitalist RRT members, and reduced autonomy for trainees. CONCLUSIONS The RRT provides advantages that extend well beyond a reduction in rates of transfers to intensive care units or codes but are balanced by certain disadvantages. The potential impact from these multiple sources should be evaluated to understand the utility of any RRT programme.
Collapse
Affiliation(s)
- Andrea L Benin
- Department of Performance Management, Yale New Haven Health System, New Haven, Connecticut 06519, USA.
| | | | | | | | | |
Collapse
|
38
|
Weingarten TN, Venus SJ, Whalen FX, Lyne BJ, Tempel HA, Wilczewski SA, Narr BJ, Martin DP, Schroeder DR, Sprung J. Postoperative emergency response team activation at a large tertiary medical center. Mayo Clin Proc 2012; 87:41-9. [PMID: 22212967 PMCID: PMC3538389 DOI: 10.1016/j.mayocp.2011.08.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 08/26/2011] [Accepted: 08/31/2011] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To study characteristics and outcomes associated with emergency response team (ERT) activation in postsurgical patients discharged to regular wards after anesthesia. PATIENTS AND METHODS We identified all ERT activations that occurred within 48 hours after surgery from June 1, 2008, through December 31, 2009, in patients discharged from the postanesthesia care unit to regular wards. For each ERT case, up to 2 controls matched for age (±10 years), sex, and type of procedure were identified. A chart review was performed to identify factors that may be associated with ERT activation. RESULTS We identified 181 postoperative ERT calls, 113 (62%) of which occurred within 12 hours of discharge from the postanesthesia care unit, for an incidence of 2 per 1000 anesthetic administrations (0.2%). Multiple logistic regression analysis revealed the following factors to be associated with increased odds for postoperative ERT activation: preoperative central nervous system comorbidity (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.20-5.32; P=.01), preoperative opioid use (OR, 2.00; 95% CI, 1.30-3.10; P=.002), intraoperative use of phenylephrine infusion (OR, 3.05; 95% CI, 1.08-8.66; P=.04), and increased intraoperative fluid administration (per 500-mL increase, OR, 1.06; 95% CI, 1.01-1.12; P=.03). ERT patients had longer hospital stays, higher complication rates, and increased 30-day mortality compared with controls. CONCLUSION Preoperative opioid use, history of central neurologic disease, and intraoperative hemodynamic instability are associated with postoperative decompensation requiring ERT intervention. Patients with these clinical characteristics may benefit from discharge to progressive or intensive care units in the early postoperative period.
Collapse
Affiliation(s)
| | - Sam J. Venus
- Department of Critical Care Medicine, Orlando Regional Medical Center, Orlando, FL
| | | | | | | | | | - Bradly J. Narr
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | | | | | - Juraj Sprung
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
- Correspondence: Address to Juraj Sprung, MD, PhD, Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905
| |
Collapse
|
39
|
Abstract
BACKGROUND Inpatients may be at risk of cardiopulmonary instability during radiologic testing. Calling the medical emergency team is one rescue intervention that brings a team of critical care providers to the unstable patient. Little is known, however, about patients' instability and activations of the medical emergency team in the radiology department (RD-MET). OBJECTIVES To describe the cause of activation of the RD-MET for hospitalized patients, temporal attributes of RD-MET involvement, characteristics of RD-MET patients, and characteristics associated with good and poor outcomes after RD-MET activation. METHODS Retrospective pilot study of RD-MET calls for 64 inpatients in a tertiary care hospital during 2009. RESULTS Reasons for RD-MET activation were 39% neurological, 38% cardiac, and 22% respiratory, and nearly half (42%) occurred during a computed tomography scan. Most RD-MET calls were made between 10 am and noon. RD-MET patients had a mean age of 61 (SD, 19) years; 52% were female, and 89% were white. Admitting diagnoses were most commonly neurological (20%), cardiovascular (16%), and abdominal (16%). The most common comorbid conditions were chronic obstructive pulmonary disease (23%) and diabetes (20%). Half of RD-MET inpatients were from a general care unit, and 56% required preexisting oxygen support. After RD-MET involvement, 61% of patients required a higher level of care; 3% died during the MET intervention, and 19% died later in hospitalization. Patients with preexisting comorbid conditions were more likely to have poor outcomes after the RD-MET intervention (P = .001). CONCLUSIONS RD-MET patients with comorbid conditions, from a general care unit, and at risk for neurological deterioration arrive in the radiology department with potentially underestimated support needs. Greater support in specific time frames and locations may be warranted to improve outcomes.
Collapse
Affiliation(s)
- Lora K Ott
- School of Nursing, University of Pittsburgh, Pennsylvania, 15261, USA.
| | | | | | | |
Collapse
|
40
|
Abstract
Sixty-three (approximately 80%) of the 81 hospitals that responded to a survey sent to all hospitals in The Netherlands with nonpediatric intensive care units had a rapid response system (RRS) in place or were in the final process of starting one. Among many other findings regarding RRS infrastructure and implementation, only 38% of the hospitals allowed nurses to activate the rapid response team without physician consent.
Collapse
Affiliation(s)
- Jeroen Ludikhuize
- Department of Internal Medicine and Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.
| | | | | | | |
Collapse
|
41
|
Boermeester MA. [Effect of emergency intervention team still unclear. More evidence is necessary]. Ned Tijdschr Geneeskd 2011; 155:A3500. [PMID: 21557829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Changes in health care culture are accompanied by a flood of initiatives with respect to patient safety and quality of care. These initiatives are incentives from government, laymen press, health insurance companies and health care providers. This makes evidence-based patient safety an absolute necessity to guide the priorities of policy makers. A medical emergency team (MET), also referred to as a rapid response team (RRT), is an example of a good initiative to improve health care quality that is being embraced rapidly worldwide, but solid evidence of its effectiveness is lacking. The number of cardiopulmonary arrests seems to have decreased, but adequate correction for case mix confounders has not been done and the effect on patient outcome, i.e. in-hospital mortality, has not been convincingly demonstrated.
Collapse
|
42
|
Meynaar IA, van Dijk H, Visser SS, Verheijen M, Dawson L, Tangkau PL. [Rapid response system in derangement of vital signs: five years experience in a large general hospital]. Ned Tijdschr Geneeskd 2011; 155:A3257. [PMID: 21586185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Hospitalized patients are at risk for adverse events such as unexpected cardiac arrest or admission to an Intensive Care Unit (ICU). Prior to these adverse events these patients often have derangements in vital signs that are not recognized and treated adequately. To identify and treat those patients at risk, our hospital implemented a rapid response system in 2004. The purpose of this paper is to describe implementation and results of our rapid response system. DESIGN Prospective cohort study. METHOD The implementation of the rapid response system started by training all doctors and nurses to score vital signs using a dedicated score card. If a patient scores 3 or more points, the patients' treating physician has to see the patient and - if necessary - call the medical emergency team (MET), consisting of an ICU physician and an ICU nurse. We analyzed all consecutive MET calls in the period January 2005-December 2009. RESULTS A total of 1058 MET calls for 981 patients were analyzed. In 606 patients (57.3%) it was decided to transfer the patient to a higher dependency unit, in most cases the ICU. In 353 patients (33.4%) treatment could be continued on the ward. In 88 patients (8.4%) it was decided that ICU treatment would not be beneficial and limits on treatment were put in place. Of the 981 patients, 255 (26.0%) died in hospital. CONCLUSION In our hospital the rapid response system has developed into an important tool for the early identification and treatment of patients at risk. However, our data cannot prove the efficacy of the rapid response system in terms of reducing hospital mortality.
Collapse
Affiliation(s)
- Iwan A Meynaar
- Reinier de Graaf Groep, afd. Intensive Care, Delft, the Netherlands.
| | | | | | | | | | | |
Collapse
|
43
|
Wheway J. Resuscitation in mental healthcare. Nurs Times 2010; 106:10-11. [PMID: 20608438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
|
44
|
Early warning system cuts code blues by 50%. Hosp Peer Rev 2009; 34:129-31. [PMID: 19886599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
|
45
|
Eftychiou C, Georgiou M, Andreou A, Michaelides A, Yiangou K, Deligeorgis A, Petrou P, Georgiou P, Christodoulides T, Makri L, Georgiou E, Patsia T, Nicolaides E, Minas M. Nicosia General Hospital cardiac arrest team: first year's practice and outcomes of in-hospital resuscitation. Hellenic J Cardiol 2009; 50:264-268. [PMID: 19622495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION In 2007, Nicosia General Hospital implemented a resuscitation policy. 378 nurses and 120 doctors were successfully trained in advanced life support (ALS) in order to staff cardiac arrest teams. The aim of this study was to assess the frequency of cardiac arrest and resuscitation outcomes in Nicosia General Hospital and assess any associations between the survival rate and the patient's characteristics. We also aimed to evaluate the effectiveness of in-hospital resuscitation in order to detect ways of improvement. METHODS We prospectively analyzed the data on all cardiac arrest calls in Nicosia General Hospital between January and December 2007. Data were collected using the Utstein style. RESULTS The cardiac arrest team (CAT) was called 83 times, of which 10 were false alarms. Cardiac arrest was identified in 69 calls, while 4 calls were respiratory arrests. The patients' mean age was 70.8 years (95% CI: 66.6-75.1). In 86% the initial rhythm was asystole/pulseless electrical activity (PEA) and in 14% ventricular fibrillation/tachycardia (VF/VT). Return of spontaneous circulation was achieved in 52% of the cases. Survival to discharge was achieved in 17.8% of the patients with arrest and in 14.5% of cardiac arrests. Patients with an initial rhythm of asystole/PEA were discharged in 5% and patients with VF/VT in 70% of cases. About 36% of the patients less than 60 years old and 12% of the patients older than 60 were discharged. The CAT arrived within 1.6 minutes, first shock in VF/VT was delivered within 1.5 minutes and the first adrenaline dose in asystole/PEA was given within 2.7 minutes. CONCLUSIONS It is more likely for our patients to survive to discharge if they are less than 60 years old, they are hospitalized in the cardiology department and the initial rhythm is VF/VT. Our outcomes are similar to survival rates in larger studies. However, points of improvement have been identified and interventions need to be made in order to improve documentation and outcomes of in-hospital arrests.
Collapse
|