Intensive care utilisation after elective surgery in Australia and New Zealand: A point prevalence study

Objective

We aimed to describe the characteristics, outcomes and resource utilisation of patients being cared for in an ICU after undergoing elective surgery in Australia and New Zealand (ANZ).

Methods

This was a point prevalence study involving 51 adult ICUs in ANZ in June 2021. Patients met inclusion criteria if they were being treated in a participating ICU on he study dates. Patients were categorised according to whether they had undergone elective surgery, admitted directly from theatre or unplanned from the ward. Descriptive and comparative analysis was performed according to the source of ICU admission. Resource utilisation was measured by Length of stay, organ support and occupied bed days.

Results

712 patients met inclusion criteria, with 172 (24%) have undergone elective surgery. Of these, 136 (19%) were admitted directly to the ICU and 36 (5.1%) were an unplanned admission from the ward. Elective surgical patients occupied 15.8% of the total ICU patient bed days, of which 44.3% were following unplanned admissions. Elective surgical patients who were an unplanned admission from the ward, compared to those admitted directly from theatre, had a higher severity of illness (AP2 17 vs 13, p<0.01), require respiratory or vasopressor support (75% vs 44%, p<0.01) and hospital mortality (16.7% vs 2.2%, p < 0.01).

Conclusions

ICU resource utilisation of patients who have undergone elective surgery is substantial. Those patients admitted directly from theatre have good outcomes and low resource utilisation. Patient admitted unplanned from the ward, although fewer, were sicker, more resource intensive and had significantly worse outcomes.

Systematic review and longitudinal analysis of implementing Artificial Intelligence to predict clinical deterioration in adult hospitals: what is known and what remains uncertain

OBJECTIVE

To identify factors influencing implementation of machine learning algorithms (MLAs) that predict clinical deterioration in hospitalized adult patients and relate these to a validated implementation framework.

MATERIALS AND METHODS

A systematic review of studies of implemented or trialed real-time clinical deterioration prediction MLAs was undertaken, which identified: how MLA implementation was measured; impact of MLAs on clinical processes and patient outcomes; and barriers, enablers and uncertainties within the implementation process. Review findings were then mapped to the SALIENT end-to-end implementation framework to identify the implementation stages at which these factors applied.

RESULTS

Thirty-seven articles relating to 14 groups of MLAs were identified, each trialing or implementing a bespoke algorithm. One hundred and seven distinct implementation evaluation metrics were identified. Four groups reported decreased hospital mortality, 1 significantly. We identified 24 barriers, 40 enablers, and 14 uncertainties and mapped these to the 5 stages of the SALIENT implementation framework.

DISCUSSION

Algorithm performance across implementation stages decreased between in silico and trial stages. Silent plus pilot trial inclusion was associated with decreased mortality, as was the use of logistic regression algorithms that used less than 39 variables. Mitigation of alert fatigue via alert suppression and threshold configuration was commonly employed across groups.

CONCLUSIONS

: There is evidence that real-world implementation of clinical deterioration prediction MLAs may improve clinical outcomes. Various factors identified as influencing success or failure of implementation can be mapped to different stages of implementation, thereby providing useful and practical guidance for implementers.

Intensive care utilisation after elective surgery in Australia and New Zealand: getting the balance right

Of the total intensive care unit (ICU) admissions in Australia and New Zealand, 36.6% occur following an elective surgical procedure. How best to use ICU services in this setting is not clear, despite this being an expensive and resource-intensive method of care delivery. The literature relating to this area has not demonstrated a clear association between improved outcomes and routine ICU utilisation. It has, however, demonstrated that methods of care delivery in this setting vary at the local, national and international level. There is now an increased interest in how we can offer safe, efficient care to patients who need ICU-level support after elective surgery, as well as where and when that care can be offered. We had previously performed a literature review relating to ICU utilisation in the elective surgical post-operative setting. This perspective piece arises from this literature review as well as extensive clinical experience from the authors. We discuss the need for a move towards an evidence-based indication for ICU admission and how this may be achieved. We then move on to the various alternative models of care that could be offered, briefly discussing their positives and potential drawbacks. We finish by outlining the research priorities and how these might be implemented in clinical practice. Getting the balance right between ICU admission and higher acuity ward-level care for post-operative elective surgical patients is difficult. However, this is an important challenge that we as a healthcare community must be working to answer.

Predictive value of a tiered escalation response system: A case control study

OBJECTIVE

Rapid response systems designed to detect and respond to clinical deterioration often incorporate a multitiered, escalation response. We sought to determine the 'predictive strength' of commonly used triggers, and tiers of escalation, for predicting a rapid response team (RRT) call, unanticipated intensive care unit admission, or cardiac arrest (events).

DESIGN

This was a nested, matched case-control study.

SETTING

The study setting involved a tertiary referral hospital.

PARTICIPANTS

Cases experienced an event, and controls were matched patients without an event.

OUTCOME MEASURES

Sensitivity and specificity and area under the receiver operating characteristic curve (AUC) were measured. Logistic regression determined the set of triggers with the highest AUC.

RESULTS

There were 321 cases and 321 controls. Nurse triggers occurred in 62%, medical review triggers in 34%, and RRT triggers 20%. Positive predictive value of nurse triggers was 59%, that of medical review triggers was 75%, and that of RRT triggers was 88%. These values were no different when modifications to triggers were considered. The AUC was 0.61 for nurses, 0.67 for medical review, and 0.65 for RRT triggers. With modelling, the AUC was 0.63 for the lowest tier, 0.71 for next highest, and 0.73 for the highest tier.

CONCLUSION

For a three-tiered system, at the lowest tier, specificity of triggers decreases, sensitivity increases, but the discriminatory power is poor. Thus, there is little to be gained by using a rapid response system with more than two tiers. Modifications to triggers reduced the potential number of escalations and did not affect tier discriminatory value.

Vital signs and medical emergency response (MER) activation predict in-hospital mortality in general surgery patients: a study of 15 969 admissions

BACKGROUND

The applicability of the vital signs prompting medical emergency response (MER) activation has not previously been examined specifically in a large general surgical cohort. This study aimed to characterize the distribution, and predictive performance, of four vital signs selected based on Australian guidelines (oxygen saturation, respiratory rate, systolic blood pressure and heart rate); with those of the MER activation criteria.

METHODS

A retrospective cohort study was conducted including patients admitted under general surgical services of two hospitals in South Australia over 2 years. Likelihood ratios for patients meeting MER activation criteria, or a vital sign in the most extreme 1% for general surgery inpatients (<0.5th percentile or > 99.5th percentile), were calculated to predict in-hospital mortality.

RESULTS

15 969 inpatient admissions were included comprising 2 254 617 total vital sign observations. The 0.5th and 99.5th centile for heart rate was 48 and 133, systolic blood pressure 85 and 184, respiratory rate 10 and 31, and oxygen saturations 89% and 100%, respectively. MER activation criteria with the highest positive likelihood ratio for in-hospital mortality were heart rate ≤ 39 (37.65, 95% CI 27.71-49.51), respiratory rate ≥ 31 (15.79, 95% CI 12.82-19.07), and respiratory rate ≤ 7 (10.53, 95% CI 6.79-14.84). These MER activation criteria likelihood ratios were similar to those derived when applying a threshold of the most extreme 1% of vital signs.

CONCLUSIONS

This study demonstrated that vital signs within Australian guidelines, and escalation to MER activation, appropriately predict in-hospital mortality in a large cohort of patients admitted to general surgical services in South Australia.

Tiered escalation response systems in practice: A post hoc analysis examining the workload implications

Objective

Many rapid response systems now have multiple tiers of escalation in addition to the traditional single tier of a medical emergency team. Given that the benefit to patient outcomes of this change is unclear, we sought to investigate the workload implications of a multitiered system, including the impact of trigger modification.

Design

The study design incorporated a post hoc analysis using a matched case-control dataset.

Setting

The study setting was an acute, adult tertiary referral hospital.

Participants

Cases that had an adverse event (cardiac arrest or unanticipated intensive care unit admission) or a rapid response team (RRT) call participated in the study. Controls were matched by age, gender, ward and time of year, and no adverse event or RRT call. Participants were admitted between May 2014 and April 2015.

Main outcome measures

The main outcome measure were the number of reviews, triggers, and modifications across three tiers of escalation; a nurse review, a multidisciplinary review (MDT-admitting medical team review), and an RRT call.

Results

There were 321 cases and 321 controls. Overall, there were 1948 nurse triggers, of which 1431 (73.5%) were in cases and 517 (26.5%) in controls, 798 MDT triggers (660 [82.7%] in cases and 138 [17.3%] in controls), and 379 RRT triggers (351 [92.6%] in cases and 28 [7.4%] in controls). Per patient per 24 h, there were 3.03 nurse, 1.24 MDT, and 0.59 RRT triggers. Accounting for modifications, this reduced to 2.17, 0.88, and 0.42, respectively. The proportion of triggers that were modified, so as not to trigger a review, was similar across all the tiers, being 28.6% of nurse, 29.6% of MDT, and 28.2% of RRT triggers. Per patient per 24 h, there were 0.61 nurse reviews, 0.52 MDT reviews, and 0.08 RRT reviews.

Conclusions

Lower-tier triggers were more prevalent, and modifications were common. Modifications significantly mitigated the escalation workload across all tiers of a multitiered system.

Protocol describing a systematic review and mixed methods consensus process to define the deteriorated ward patient

INTRODUCTION

Most patients admitted to hospital recover with treatments that can be administered on the general ward. A small but important group deteriorate however and require augmented organ support in areas with increased nursing to patient ratios. In observational studies evaluating this cohort, proxy outcomes such as unplanned intensive care unit admission, cardiac arrest and death are used. These outcome measures introduce subjectivity and variability, which in turn hinders the development and accuracy of the increasing numbers of electronic medical record (EMR) linked digital tools designed to predict clinical deterioration. Here, we describe a protocol for developing a new outcome measure using mixed methods to address these limitations.

METHODS AND ANALYSIS

We will undertake firstly, a systematic literature review to identify existing generic, syndrome-specific and organ-specific definitions for clinically deteriorated, hospitalised adult patients. Secondly, an international modified Delphi study to generate a short list of candidate definitions. Thirdly, a nominal group technique (NGT) (using a trained facilitator) will take a diverse group of stakeholders through a structured process to generate a consensus definition. The NGT process will be informed by the data generated from the first two stages. The definition(s) for the deteriorated ward patient will be readily extractable from the EMR.

ETHICS AND DISSEMINATION

This study has ethics approval (reference 16399) from the Central Adelaide Local Health Network Human Research Ethics Committee. Results generated from this study will be disseminated through publication and presentation at national and international scientific meetings.

Impact of a standardised rapid response system on clinical outcomes of female patients: an interrupted time series approach

Background

This study aimed to assess the impact of a standardised rapid response systems (the Between the Flags (BTF)) implemented across New South Wales (NSW), Australia, among female patients.

Methods

We conducted an interrupted time series (2007–2013) population-based linkage study including 5 114 170 female patient (≥18 years old) admissions in all 232 public hospitals in NSW. We studied changes in levels and trends of patient outcomes after BTF implementation among four age groups of female patients.

Results

Before the BTF system introduction (2007–2009), for the female patients as a whole, there was a progressive decrease in rates of in-hospital cardiopulmonary arrest (IHCA), IHCA-related mortality and hospital mortality for female patients. However, there were no changes in deaths in low-mortality diagnostic-related groups (DLMDRGs), IHCA survival to discharge and 1-year post-discharge mortality after surviving an IHCA. Only the female patients aged 55 years and older showed the same results as the whole sample. After the BTF programme (2010–2013), the same trends (except for DLMDRG) continued for female patients as a whole and for those aged 55 years or older. There was a significant reduction in DLMDRG among female patients aged 35–54 years (p<0.001), those aged 75 years and over (p<0.05) and female patients as a whole (p<0.05). The decreasing secular trend of surviving an IHCA to hospital discharge before the BTF system (p<0.05) among patients aged 18–34 years old was reversed after the BTF implementation (p<0.01).

Conclusions

For female patients the BTF programme introduction was associated with continued reductions in the rates of IHCA, IHCA-related mortality and hospital mortality, as well as a new reduction in DLMDRG for 35–54 years old patients and those aged 75 years and older, and increased survival for those aged 18–34 years who had suffered an IHCA.

Acute clinical deterioration and consumer escalation: The understanding and perceptions of hospital staff

Introduction

Consumer escalation systems allow patients and families to escalate concerns about acute clinical deterioration. Hospital staff can impact upon the success of this process. As part of evaluation processes within a Local Health Network, where a consumer escalation system was introduced in accordance with National requirements, we sought to explore clinicians’ understanding and perceptions of consumer escalation.

Methods

Voluntary and anonymous staff surveys pre, and post, system introduction. Quantitative data was analysed using descriptive statistics, chi-square independence, and non-parametric independent samples median tests. Qualitative data was evaluated using content analysis and cross-referenced with quantitative responses.

Results

Respondent’s (pre: 215; post: 89) area of work varied significantly between survey periods. Most agreed that patients/families have a sound knowledge of a patient’s typical health status (pre: 192/215 (89.3%); post 82/88 (93.2%)) and that patients/families should be encouraged to escalate concerns of deterioration to ward staff (pre: 209/212 (98.6%); post: 85/89 (95.5%)). Respondent perceptions of patient/family ability to recognise clinical deterioration varied. Staff agreement towards local response expectations decreased as the degree of clinical requirement increased. Staff concerns of increased workloads (pre: 90/214 (42.1%); post 12/72 (16.7%), p<0.001) and conflict generation (pre: 71/213 (33.3%); post: 7/71 (9.9%), p = 0.001) decreased significantly following system introduction. However, clinician perceptions of positive system effects also decreased (patient-staff rapport pre: 163/213 (76.5%); post: 38/72 (52.8%), p = 0.001; patient centred care pre: 188/214 (87.9%); post: 53/72 (73.6%), p = 0.012; patient safety pre: 173/214 (80.8%); post: 49/72 (68.1%), p = 0.077). Only 53% of respondents (pre: 112/213 (52.6%); post: 48/88 (54.5%)) perceived that patient/family have sufficient confidence to escalate concerns.

Conclusion

Consumer escalation systems require staff support. Staff perceptions may indicate, and act as, barriers to the operation of consumer escalation processes. Further exploration in identifying and managing staff barriers is crucial to the success of consumer escalation.

Acute clinical deterioration and consumer escalation in the hospital setting: A literature review

BACKGROUND

Consumer escalation systems that allow patients and/or their family/carers to escalate concerns about clinical deterioration have been proposed as a way of enhancing patient safety. However, evidence to guide implementation or to support system effectiveness remains unclear.

AIM

To critically evaluate the current evidence surrounding consumer escalation within the context of clinical deterioration to identify the strengths, weaknesses and gaps in existing knowledge, essential themes, and directions for further investigation.

METHOD

Database searches were conducted within Cumulative Index of Nursing and Allied Health Literature, PubMed, and the Cochrane Library for articles directly relating to consumer escalation systems published, in English, within the previous 10 year-period. Titles and abstracts were screened and relevant full-text articles included. Content was examined to identify breadth of knowledge, essential themes, and the effectiveness of current systems.

RESULTS

27 articles, containing a mixture of both quantitative and qualitative findings, were identified. Within the context of limitations in the overall depth and quality of current evidence, four key areas (relating to consumer understanding and awareness of clinical deterioration, confidence and ability to escalate concerns, education, and staff attitudes) were identified as potentially critical to the foundation, functioning, and success of consumer escalation systems. Consumer escalation processes may contribute positive effects beyond mortality rates; however, an agreed method of assessing effectiveness remains undetermined.

CONCLUSIONS

The ability of consumer escalation processes to achieve their underlying goals is still to be adequately assessed. Further research is required to inform how to best implement, support and optimise consumer escalation systems.

Perceptions of interactions between staff members calling, and those responding to, rapid response team activations for patient deterioration

Objectives The aim of the present study was to investigate experiences of staff interactions and non-technical skills (NTS) at rapid response team (RRT) calls, and their association with repeat RRT calls. Methods Mixed-methods surveys were conducted of RRT members and staff who activate the RRT (RRT users) for their perceptions and attitudes regarding the use of NTS during RRT calls. Responses within the survey were recorded as Likert items, ranked data and free comments. The latter were coded into nodes relating to one of four NTS domains: leadership, communication, cooperation and planning. Results Two hundred and ninety-seven (32%) RRT users and 79 (73.8%) RRT members provided responses. Of the RRT user respondents, 76.5% had activated the RRT at some point. Deficits in NTS at RRT calls were revealed, with 36.9% of users not feeling involved during RRT calls and 24.7% of members perceiving that users were disinterested. Unresolved user clinical concerns, or persistence of RRT calling criteria, were reasons cited by 37.6% and 23%, respectively, of RRT users for reactivating an RRT to the same patient. Despite recollections of conflict at previous RRT calls, 92% of users would still reactivate the RRT. The most common theme in the free comments related to deficiencies in cooperation (52.9%), communication (28.6%) and leadership (14.3%). Conclusions This survey of RRT users and members revealed problems with RRT users' and members' interactions at the time of an RRT call. Both users and members considered NTS to be important, but lacking. These findings support NTS training for RRT members and users. What is known about the topic? Previous surveying has related experiences of criticism and conflict between clinical staff at RRT activations. This leads to reluctance to call the RRT when indicated, with risks to patient safety, especially if subsequent RRT activation is necessary. Training in NTS has improved clinician interactions in simulated emergencies, but the exact role of NTS during RRT calls has not yet been established. What does this paper add? The present survey examined experienced clinicians' perceptions of the use of NTS at RRT calls and the effect on subsequent calling. A key finding was a disparity between perceptions of how RRT members interact with those activating the RRT (RRT users) and their performance of NTS. This was reflected with unresolved RRT user clinical concern at the time of a call. In turn, this affected RRT users' attitudes and intentions to reactivate the RRT. Formal handover was considered desirable by both RRT users and members. What are the implications for practitioners? The interface between the RRT and those who call the RRT is crucial. This survey shows that RRT users desire to be included in the management of the deteriorating patient and have their concerns addressed before completion of RRT attendance. Failure to do so results in repeat activations to the same patient, with the potential for adverse patient outcomes. Training to include NTS, especially around handover, for RRT members may address this issue and should be explored further.

Hospital variability of postoperative sepsis and sepsis-related mortality after elective coronary artery bypass grafting surgery

PURPOSE

Hospital variability of postoperative sepsis and sepsis-related mortality after elective CABG surgery was not known in Australia.

MATERIAL AND METHODS

Population-based analysis of all elective patients who underwent CABG surgery in public and private hospitals between 2007 and 2014 using linked data from the state-wide Admitted Patient Data Collection and the NSW Registry of Births, Deaths, and Marriages.

RESULTS

We identified 18,928 (9464 pairs) matched patients who had elective CABG surgery in public hospitals (n = 9) and private hospitals (n = 13) during the study period. When compared to public hospital patients, private hospital patients had a significantly lower rate of post-CABG sepsis (13.3 vs 20.4 per 1000 admissions, P < 0.001; treatment effects: -7.1, 95%CI: -11.1 to -3.3), a lower in-hospital mortality rate (6.1 vs 9.9 per 1000 admissions, P = 0.006; treatment effects: -3.8, 95%CI: -6.5 to -1.1), and a lower rate of 30-day readmission (11.9% vs 13.9%, P < 0.001; treatment effects: -2.0%, 95%CI: -3.1% to -1.0%). In addition, for both public and private hospital groups, there were significant differences for all outcomes when comparing the worst and best performance quintile hospitals.

CONCLUSIONS

Hospital variability of postoperative sepsis, in-hospital mortality and readmission after elective CABG existed between and within public and private hospitals.

Elderly patients are at high risk of night-time admission to the intensive care unit following a rapid response team call

Previous studies have shown that elderly patients (age ≥65 years) are less likely to be admitted to the intensive care unit following a rapid response team call and have high hospital mortality rates. This study has shown that elderly patients have a significantly higher probability of being admitted to an intensive care unit following a rapid response team call at night than during the day. However, at no time are they at greater risk than younger patients of incomplete vital sign recording, a failure to escalate care for acute deterioration or mortality.

Rapid response team calls that overlap in time: incidence, consequences and patient outcomes

OBJECTIVE

To investigate overlap rapid response team (RRT) calls, factors associated with overlap calls, and their impact on RRT call times and patient outcomes.

DESIGN AND SETTING

Review of prospectively collected, linked clinical and administrative datasets, at a public adult tertiary hospital during July 2013 to May 2016.

RESULTS

There were 11 669 RRT calls to 7223 patients, of which 10 868 calls (93.1%) were to inpatients. The median number of daily calls was 12 (interquartile range [IQR], 9-15 calls; range, 2-29 calls). The median number of daily calls per 1000 hospital admissions was 56.3 (IQR, 41.3- 78.9 calls/1000 admissions; range, 8.3-231.5 calls/1000 admissions), and the median proportion of the day spent at RRT calls was 22.8% (IQR, 16.9%-30.5%). In total, 4575 (39.2%) calls overlapped. Overlap calls, compared with non-overlap calls, had similar patient characteristics, but a longer response time (4 min v 3 min; P < 0.001) and scene time (20 min v 34 min; P < 0.001). The daily number of calls correlated with the number of overnight-stay hospital admissions (r = 0.104; P = 0.001), but not with the total number of hospital admissions (r = -0.035; P = 0.258). The number of overlap calls correlated with the number of RRT calls (r = 0.786; P < 0.001), and also correlated with the proportion of the day spent at RRT calls (r = 0.762; P < 0.001). Overlap calls, compared with non-overlap calls, were more likely to result in an ICU admission (484 calls [11.2%] v 571 calls [8.7%]; P < 0.001). In contrast, efferent limb failure (815 calls [17.8%] v 1195 calls [16.8%]; P = 0.389) and hospital mortality (496 calls [19.3%] v 781 calls [19.6%]; P = 0.823) was similar for overlap and nonoverlap calls, respectively.

CONCLUSIONS

Overlap RRT calls are common and influenced by overall RRT and hospital activity. They are more likely to be associated with longer response and scene times and unanticipated ICU admissions.

A newly designed observation and response chart's effect upon adverse inpatient outcomes and rapid response team activity

BACKGROUND

Adverse inpatient events may diminish with earlier response to clinical deterioration. Observation and response charts with a tiered escalation response are recommended for use.

AIMS

To examine the impact of an observation and response chart and altered calling criteria on rapid response team (RRT) calls, cardiac arrests and intensive care unit (ICU) admissions from the ward and hospital deaths.

METHODS

Linked administrative and clinical data from an Australian, adult tertiary hospital for August 2007 to June 2013 (pre-chart) and July 2013 to December 2014 (post-chart) and analysed using interrupted time series analysis.

RESULTS

Pre-chart RRT calls were increasing by 1.7 calls per 10 000 hospital admissions per month, whilst ICU admissions from the ward, deaths and cardiac arrests were decreasing by 0.3, 0.25 and 0.079 per 10 000 admissions per month respectively. Immediately upon chart introduction, the RRT call rate increased by 82% (66-98% CI; P < 0.01), the ward admissions to ICU rate increased by 41% (14-67% CI; P < 0.01) and the rates of deaths and cardiac arrests did not change. In the post chart period, both the pre-chart increasing trend in the rate of RRT and decreasing trend in the rate of ICU admissions changed significantly to become constant. The pre chart trends in the cardiac arrest rate and hospital mortality did not change.

CONCLUSION

Observation and response charts increased RRT and ICU workload without improving cardiac arrest rate or mortality. Future chart evaluation should identify features beneficial to patient outcomes and refine those that consume critical care resources that are not associated with improved patient outcomes.

The impact of post-operative sepsis on mortality after hospital discharge among elective surgical patients: a population-based cohort study

Background

Our aim in the present study was to assess the mortality impact of hospital-acquired post-operative sepsis up to 1 year after hospital discharge among adult non-short-stay elective surgical patients.

Methods

We conducted a population-based, retrospective cohort study of all elective surgical patients admitted to 82 public acute hospitals between 1 January 2007 and 31 December 2012 in New South Wales, Australia. All adult elective surgical admission patients who stayed in hospital for ≥4 days and survived to discharge after post-operative sepsis were identified using the Admitted Patient Data Collection records linked with the Registry of Births, Deaths, and Marriages. We assessed post-discharge mortality rates at 30 days, 60 days, 90 days and 1 year and compared them with those of patients without post-operative sepsis.

Results

We studied 144,503 survivors to discharge. Of these, 1857 (1.3%) had experienced post-operative sepsis. Their post-discharge mortality rates at 30 days, 60 days, 90 days and 1 year were 4.6%, 6.7%, 8.1% and 13.5% (vs 0.7%, 1.2%, 1.5% and 3.8% in the non-sepsis cohort), respectively (P < 0.0001 for all). After adjustment for patient and hospital characteristics, post-operative sepsis remained independently associated with a higher mortality risk (30-day mortality HR 2.75, 95% CI 2.14–3.53; 60-day mortality HR 2.45, 95% CI 1.94–3.10; 90-day mortality HR 2.31, 95% CI 1.85–2.87; 1-year mortality HR 1.71, 95% CI 1.46–2.00). Being older than 75 years of age (HR 3.50, 95% CI 1.56–7.87) and presence of severe/very severe co-morbidities as defined by Charlson co-morbidity index (severe vs normal HR 2.05, 95% CI 1.45–2.89; very severe vs normal HR 2.17, 95% CI 1.49–3.17) were the only other significant independent predictors of increased 1-year mortality.

Conclusions

Among elective surgical patients, post-operative sepsis is independently associated with increased post-discharge mortality up to 1 year after hospital discharge. This risk is particularly high in the first month, in older age patients and in the presence of severe/very severe co-morbidities. This high-risk population can be targeted for interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1596-7) contains supplementary material, which is available to authorized users.

Incidences and variations of hospital acquired venous thromboembolism in Australian hospitals: a population-based study

BACKGROUND

Data on hospital-acquired venous thromboembolism (HA-VTE) incidence, case fatality rate and variation amongst patient groups and health providers is lacking. We aim to explore HA-VTE incidences, associated mortality, trends and variations across all acute hospitals in New South Wales (NSW)-Australia.

METHODS

A population-based study using all admitted patients (aged 18-90 with a length of stay of at least two days and not transferred to another acute care facility) in 104 NSW acute public and private hospitals during 2002-2009. Poisson mixed models were used to derive adjusted rate ratios (IRR) in presence of patient and hospital characteristics.

RESULTS

Amongst, 3,331,677 patients, the incidence of HA-VTE was 11.45 per 1000 patients and one in ten who developed HA-VTE died in hospital. HA-VTE incidence, initially rose, but subsequently declined, whereas case fatality rate consistently declined by 22 % over the study period. Surgical patients were 128 % (IRR = 2.28, 95 % CI: 2.19-2.38) more likely to develop HA-VTE, but had similar case fatality rates compared to medical patients. Private hospitals, in comparison to public hospitals had a higher incidence of HA-VTE (IRR = 1.76; 95 % CI: 1.42-2.18) for medical patients. However, they had a similar incidence (IRR = 0.91; 95 % CI: 0.75-1.11), but a lower mortality (IRR = 0.59; 95 % CI: 0.47-0.75) amongst surgical patients. Smaller public hospitals had a lower HA-VTE incidence rate compared to larger hospitals (IRR < 0.68) but a higher case fatality rate (IRR > 1.71). Hospitals with a lower reported HA-VTE incidence tended to have a higher HA-VTE case fatality rate.

CONCLUSION

Despite the decline in HA-VTE incidence and case fatality, there were large variations in incidents between medical and surgical patients, public and private hospitals, and different hospital groups. The causes of such differences warrant further investigation and may provide potential for targeted interventions and quality improvement initiatives.

Impact of a standardized rapid response system on outcomes in a large healthcare jurisdiction

AIM

To assess the impact of a standardized rapid response system (RRS) implemented across a large health care jurisdiction on reducing serious adverse events, hospital mortality and unexpected deaths.

METHOD

We conducted an interrupted time series (2007-2013) population-based study in the state of New South Wales (NSW), Australia to evaluate the impact of introducing a statewide standardized RRS (the between-the-flags [BTF] system) which employed a five-component intervention strategy. We studied 9,799,081 admissions in all 232 public hospitals in NSW. We studied changes in trends for annual rates of multiple key patient-centered outcomes before and after its introduction.

RESULTS

Before the BTF system (2007-2009), there was a progressive decrease in mortality, cardiac arrest rates, cardiac arrests related mortality, and failure to rescue rates, but no changes in mortality rate among low mortality diagnostic related group (LMDRGs) patients. After the BTF program (2010-2013), the same trends continued for all outcomes with an overall (2013 vs 2007) 46% reduction in cardiac arrest rates; a 54% reduction in cardiac arrest related mortality rates; a 19% reduction in hospital mortality; a 35% decrease in failure to rescue rates (all Ps<0.001) over seven-years. In addition, there was a new 20% (p<0.001) mortality reduction among LMDRG patients (2013 vs 2007).

CONCLUSIONS

The BTF program was associated with continued decrease in the overall cardiac arrests rates, deaths after cardiac arrest, hospital mortality and failure to rescue. In addition, among patients in the LMDRC group, it induced a new and significant post-intervention reduction in mortality which was never reported before.

Incidence and mortality of postoperative sepsis in New South Wales, Australia, 2002-2009

OBJECTIVE

To describe the incidence and mortality of postoperative sepsis in New South Wales, Australia.

DESIGN, SETTING AND PARTICIPANTS

A retrospective study of adult elective surgical admissions (n = 229 918) in 82 public acute care hospitals in NSW, 2002-2009.

MAIN OUTCOME MEASURES

Changes in the incidence rate of post-operative sepsis and sepsis-related mortality.

RESULTS

Although the mortality rate among patients with sepsis decreased from 26.9% in 2002 to 20.2% in 2009 (P = 0.006 for adjusted trend), the incidence rate of sepsis increased from 12.7 to 15.8 per 1000 admissions (adjusted rate ratio [RR], 1.23; 95% CI, 1.06-1.42). Thus, the incidence rate of sepsis-related deaths remained unchanged (3.4 v 3.2 per 1000 admissions; adjusted RR, 0.90; 95% CI, 0.67-1.22), as did deaths from sepsis as a proportion of all elective surgical deaths (P = 0.96 for adjusted trend). The incidence rate of infections without a specified organism identified increased; was twice the rate of gram-positive infections (8.5 v 4.1 per 1000 admissions, P < 0.001); and was three times the rate of gram-negative infections (8.5 v 2.7 per 1000 admissions, P < 0.001). Also, compared with patients with gram-positive infections, patients with an unspecified infection were more likely to die (adjusted RR, 1.33; 95% CI, 1.13-1.57), but patients with gram-negative infections and mixed infections had a similar likelihood of death from their infection.

CONCLUSION

Over 8 years, the mortality from postoperative sepsis decreased, but its incidence rate increased, resulting in a lack of improvement in the incidence rate of sepsis-related deaths. The increasing incidence of postoperative sepsis and the poor record of identification of causative organisms remain a significant public health challenge.

Diurnal variation in the performance of rapid response systems: the role of critical care services-a review article

The type of medical review before an adverse event influences patient outcome. Delays in the up-transfer of patients requiring intensive care are associated with higher mortality rates. Timely detection and response to a deteriorating patient constitute an important function of the rapid response system (RRS). The activation of the RRS for at-risk patients constitutes the system’s afferent limb. Afferent limb failure (ALF), an important performance measure of rapid response systems, constitutes a failure to activate a rapid response team (RRT) despite criteria for calling an RRT.

There are diurnal variations in hospital staffing levels, the performance of rapid response systems and patient outcomes. Fewer ward-based nursing staff at night may contribute to ALF. The diurnal variability in RRS activity is greater in unmonitored units than it is in monitored units for events that should result in a call for an RRT. RRT events include a significant abnormality in either the pulse rate, blood pressure, conscious state or respiratory rate. There is also diurnal variation in RRT summoning rates, with most activations occurring during the day. The reasons for this variation are mostly speculative, but the failure of the afferent limb of RRT activation, particularly at night, may be a factor.

The term “circadian variation/rhythm” applies to physiological variations over a 24-h cycle. In contrast, diurnal variation applies more accurately to extrinsic systems. Circadian rhythm has been demonstrated in a multitude of bodily functions and disease states.

For example, there is an association between disrupted circadian rhythms and abnormal vital parameters such as anomalous blood pressure, irregular pulse rate, aberrant endothelial function, myocardial infarction, stroke, sleep-disordered breathing and its long-term consequences of hypertension, heart failure and cognitive impairment. Therefore, diurnal variation in patient outcomes may be extrinsic, and more easily modifiable, or related to the circadian variation inherent in human physiology. Importantly, diurnal variations in the implementation and performance of the RRS, as gauged by ALF, the RRT response to clinical deterioration and any variations in quality and quantity of patient monitoring have not been fully explored across a diverse group of hospitals.

Multi-Tiered Observation and Response Charts: Prevalence and Incidence of Triggers, Modifications and Calls, to Acutely Deteriorating Adult Patients

BACKGROUND

Observation charts are the primary tool for recording patient vital signs. They have a critical role in documenting triggers for a multi-tiered escalation response to the deteriorating patient. The objectives of this study were to ascertain the prevalence and incidence of triggers, trigger modifications and escalation response (Call) amongst general medical and surgical inpatients following the introduction of an observation and response chart (ORC).

METHODS

Prospective (prevalence), over two 24-hour periods, and retrospective (incidence), over entire hospital stay, observational study of documented patient observations intended to trigger one of three escalation responses, being a MER-Medical Emergency Response [highest tier], MDT-Multidisciplinary Team [admitting team], or Nurse-senior ward nurse [lowest tier] response amongst adult general medical and surgical patients.

RESULTS

PREVALENCE

416 patients, 321 (77.2%) being medical admissions, median age 76 years (IQR 62, 85) and 95 (22.8%) Not for Resuscitation (NFR). Overall, 193 (46.4%) patients had a Trigger, being 17 (4.1%) MER, 45 (10.8%) MDT and 178 (42.8%) Nurse triggers. 60 (14.4%) patients had a Call, and 72 (17.3%) a modified Trigger.

INCIDENCE

206 patients, of similar age, of whom 166 (80.5%) had a Trigger, 122 (59.2%) a Call, and 91 (44.2%) a modified Trigger. PREVALENCE and incidence of failure to Call was 33.2% and 68% of patients, respectively, particular for Nurse Triggers (26.7% and 62.1%, respectively). The number of Modifications, Calls, and failure to Call, correlated with the number of Triggers (0.912 [p<0.01], 0.631 [p<0.01], 0.988 [p<0.01]).

CONCLUSION

Within a multi-tiered response system for the detection and response to the deteriorating patient Triggers, their Modifications and failure to Call are common, particularly within the lower tiers of escalation. The number of Triggers and their Modifications may erode the structure, compliance, and potential efficacy of structured observation and response charts within a multi-tiered response system.

Geographic variation of failure-to-rescue in public acute hospitals in New South Wales, Australia

Despite the wide acceptance of Failure-to-Rescue (FTR) as a patient safety indicator (defined as the deaths among surgical patients with treatable complications), no study has explored the geographic variation of FTR in a large health jurisdiction. Our study aimed to explore the spatiotemporal variations of FTR rates across New South Wales (NSW), Australia. We conducted a population-based study using all admitted surgical patients in public acute hospitals during 2002-2009 in NSW, Australia. We developed a spatiotemporal Poisson model using Integrated Nested Laplace Approximation (INLA) methods in a Bayesian framework to obtain area-specific adjusted relative risk. Local Government Area (LGA) was chosen as the areal unit. LGA-aggregated covariates included age, gender, socio-economic and remoteness index scores, distance between patient residential postcode and the treating hospital, and a quadratic time trend. We studied 4,285,494 elective surgical admissions in 82 acute public hospitals over eight years in NSW. Around 14% of patients who developed at least one of the six FTR-related complications (58,590) died during hospitalization. Of 153 LGAs, patients who lived in 31 LGAs, accommodating 48% of NSW patients at risk, were exposed to an excessive adjusted FTR risk (10% to 50%) compared to the state-average. They were mostly located in state's centre and western Sydney. Thirty LGAs with a lower adjusted FTR risk (10% to 30%), accommodating 8% of patients at risk, were mostly found in the southern parts of NSW and Sydney east and south. There were significant spatiotemporal variations of FTR rates across NSW over an eight-year span. Areas identified with significantly high and low FTR risks provide potential opportunities for policy-makers, clinicians and researchers to learn from the success or failure of adopting the best care for surgical patients and build a self-learning organisation and health system.

Rate of venous thromboembolism among surgical patients in Australian hospitals: a multicentre retrospective cohort study

OBJECTIVES

Despite the burden of venous thromboembolism (VTE) among surgical patients on health systems in Australia, data on VTE incidence and its variation within Australia are lacking. We aim to explore VTE and subsequent mortality rates, trends and variations across Australian acute public hospitals.

SETTING

A large retrospective cohort study using all elective surgical patients in 82 acute public hospitals during 2002-2009 in New South Wales, Australia.

PARTICIPANTS

Patients underwent elective surgery within 2 days of admission, aged between 18 and 90 years, and who were not transferred to another acute care facility; 4 362 624 patients were included.

OUTCOME MEASURES

VTE incidents were identified by secondary diagnostic codes. Poisson mixed models were used to derive adjusted incidence rates and rate ratios (IRR).

RESULTS

2/1000 patients developed postoperative VTE. VTE increased by 30% (IRR=1.30, CI 1.19 to 1.42) over the study period. Differences in the VTE rates, trends between hospital peer groups and between hospitals with the highest and those with the lowest rates were significant (between-hospital variation). Smaller hospitals, accommodated in two peer groups, had the lowest overall VTE rates (IRR=0.56:0.33 to 0.95; IRR=0.37:0.23 to 0.61) and exhibited a greater increase (64% and 237% vs 19%) overtime and greater between-hospital variations compared to larger hospitals (IRR=8.64:6.23 to 11.98; IRR=8.92:5.49 to 14.49 vs IRR=3.70:3.32 to 4.12). Mortality among patients with postoperative VTE was 8% and remained stable overtime. No differences in post-VTE death rates and trends were seen between hospital groups; however, larger hospitals exhibited less between-hospital variations (IRR=1.78:1.30 to 2.44) compared to small hospitals (IRR>23). Hospitals performed differently in prevention versus treatment of postoperative VTE.

CONCLUSIONS

VTE incidence is increasing and there is large variation between-hospital and within-hospital peer groups suggesting a varied compliance with VTE preventative strategies and the potential for targeted interventions and quality improvement opportunities.

Documentation of limitation of medical therapy at the time of a rapid response team call

OBJECTIVES

The aims of the present study were to: (1) describe the documentation process of limitation of medical therapy (LMT) orders at the time of a rapid response team (RRT) call; and (2) compare documented LMT orders not associated with an RRT call (control, Group 1) with LMT orders documented at the time of an RRT call (Group 2).

METHODS

A descriptive study, over a 6-month period (February-August 2011), involving the review of the medical records of patients prospectively identified as either Group 1 or Group 2.

RESULTS

There were 994 RRT calls; of these, 50 patients (5%) had an LMT order documented by the RRT. A cardiac arrest was the trigger for the RRT for six patients (12%). Patients in Group 1 (n=50) and Group 2 were of similar median age (80.5 vs 78.5 years; P=0.30), LMTs were recorded at a similar time of day (15:30 vs 15:55 hours; P=0.52) and day of the week (weekend: 32% vs 35%; P=0.72). Comparing group 2 with Group 1, the RRT was less likely to document a not-for-resuscitation (NFR; 31 (62%) vs 49 (98%); P<0.01) or a not-for-ICU (NFICU; 18 (36%) vs 41 (82%); P<0.01) order, but more likely to document a not-for-RRT call (NFRRT; 31 (62%) vs 22 (44%); P=0.04) and modified RRT calling criteria (MRRT; 4 (8%) vs 0 (0%); P=0.04) orders. For Group 2 compared with Group 1 orders, involvement of the patient in the decision making process (9 (18%) vs 25 (50%); P<0.01) or the next of kin (29 (58%) vs 45 (90%); P<0.01) was documented less often.

CONCLUSIONS

Documentation of LMT orders at the time of an RRT call is less likely to include documented involvement of patients or their next of kin, and is more likely to be an NFRRT or MRRT order. These findings have implications for overall clinical governance. What is known about the topic? RRT are not infrequently involved in documenting LMT orders. What does this paper add? This is the first study in Australasia to look into the timing and circumstances surrounding the issuing of a NFR order during an RRT call. The study findings clarify the type of LMT orders documented by RRT and to what extent patients, their carers and senior medical staff are involved. What are the implications for practitioners? Our findings indicate that, in the setting of a rapid response system, there is a need to consider beyond the narrow interpretation of the NFR order, when a NFRRT may also be appropriate. This will require standardisation of such nomenclature, and training and education of those involved in documenting and interpreting such orders. Equally, it will require a different approach to the discussion with patients and their carers as to what the implications of an NFRRT order are. The findings also have significant implications as to the senior medical oversight of LMT, in particular for RRT, for whom it is their first encounter with such patients. Finally, the findings suggest that consideration be given to better delineating the documentation of the role of nursing staff when setting LMT orders.

Utility and assessment of non-technical skills for rapid response systems and medical emergency teams

Efforts are ongoing to improve outcomes from cardiac arrest and medical emergencies. A promising quality improvement modality is use of non-technical skills (NTS) that aim to address human factors through improvements in performance of leadership, communication, situational awareness and decision-making. Originating in the airline industry, NTS training has been successfully introduced into anaesthesia, surgery, emergency medicine and other acute medical specialities. Some aspects of NTS have already achieved acceptance for cardiac arrest teams. Leadership skills are emphasised in advanced life support training and have shown favourable results when employed in simulated and clinical resuscitation scenarios. The application of NTS in medical emergency teams as part of a rapid response system attending medical emergencies is less certain; however, observations of simulations have also shown promise. This review highlights the potential benefits of NTS competency for cardiac arrest teams and, more importantly, medical emergency teams because of the diversity of clinical scenarios encountered. Discussion covers methods to assess and refine NTS and NTS training to optimise performance in the clinical environment. Increasing attention should be applied to yielding meaningful patient and organisational outcomes from use of NTS. Similarly, implementation of any training course should receive appropriate scrutiny to refine team and institutional performance.

Patients admitted to Australian intensive care units: impact of remoteness and distance travelled on patient outcome

OBJECTIVE

To use a geographical information system (GIS) to explore the impact of (i) patient remoteness and (ii) distance travelled to an Australian public-hospital intensive care unit on patient outcomes.

DESIGN, SETTING AND SUBJECTS

We conducted a retrospective study over the period 2002-2008 linking intensive care unit resource and clinical datasets with Australian population postcode data and using a GIS for analysis. Data from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS CORE) critical care resources survey (2007), the ANZICS CORE adult patient database (2002- 2008) and the Australian Bureau of Statistics were used. Only public-hospital ICUs were included in the study. Classification of remoteness was based on the extended version of the Accessibility/Remoteness Index of Australia (ARIA+). Distance was the distance between centroids of the patient's residential postcode and the postcode of the area in which the admitting ICU was located. ICU admissions were divided into three categories: "direct other-hospital ICU admission" (patient transferred directly from another hospital), "indirect other-hospital ICU admission" (patient admitted from a ward, emergency department or operating room after being transferred from another hospital) or "home ICU admission" (patient not transferred from another hospital).

MAIN OUTCOME MEASURE

Hospital mortality.

RESULTS

There were 218 709 ICU admissions to 76 Australian public hospital ICUs. Of these admissions, 49 674 (22.7%) were in the "indirect" group and 19 494 (8.9%) in the "direct" group. Over the period of the study, for the indirect and direct groups, remoteness (measured by median ARIA+ rating) increased (from 0.25 to 0.55 [P < 0.01] and from 0.12 to 0.25 [P < 0.01], respectively) as did median distance travelled to the admitting ICU (from 36.4 to 42.5 km [P < 0.01] and from 27.1 to 36.7 km [P < 0.01], respectively), while mortality decreased (from 18.2% to 15.8% [P = 0.01] and from 22.7% to 18.7% [P = 0.01], respectively). ICU length of stay (LOS) and hospital LOS correlated with ARIA+ rating for both the indirect group (R = 0.018, P < 0.01; and R = 0.013, P < 0.01, respectively) and the direct group (R = 0.038, P < 0.01; and R = 0.036, P < 0.01, respectively). The median distance travelled by survivors compared with non-survivors was similar in the direct group (30.8 v 32.1 km [P = 0.66]) but longer in the indirect group (42.8 v 33.8 km [P < 0.01]) and the home admission group (11.5 v 7.6 km [P < 0.01]).

CONCLUSION

For patients who were admitted to the ICU after being transferred from another hospital, greater remoteness and greater distance travelled were not associated with increased mortality, but LOS in the hospital and the ICU was longer.

Direct and delayed admission to an intensive care or high dependency unit following discharge from the emergency department: associated patient characteristics and hospital outcomes

OBJECTIVE

To compare patients admitted from the emergency department (ED) directly to a ward (EDWard), the intensive care unit (EDICU) or stepdown (high dependency) unit (EDSDU) with patients admitted via the ED, but whose admission to an ICU (EDWardICU) or SDU (EDWardSDU) was preceded by a ward stay.

DESIGN, SETTING AND PARTICIPANTS

Administrative and clinical data linkage; 650-bed, tertiary referral hospital, whose ED has about 60 000 patient presentations per annum; adult patients admitted via the ED to a ward, ICU or SDU and whose ED length of stay (LOS) was < 24 h.

MAIN OUTCOME MEASURE

Hospital outcome and stay.

RESULTS

From January 2004 to December 2007, there were 43 484 patients, of whom 40 609 (93.4%) were EDWard, 1020 (2.3%) were EDICU, 873 (2.0%) were EDSDU, 503 (1.2%) were EDWardSDU, and 479 (1.1%) were EDWardICU. Hospital mortality for EDWardICU patients exceeded that of EDICU patients (34.9% v 23.3%; P < 0.01), as did EDWardSDU exceed EDSDU (12.3% v 7.8%; P < 0.01). Median ward stay for EDWardICU patients was 47 h 37 min (IQR, 14 h 48 min - 131 h 53 min) and for EDWardSDU patients, 46 h 18min (IQR, 18h 28 min - 140h 12 min) (P=0.75). Compared with patients admitted to the ICU from the operating theatre, EDWardICU patients had a longer median ward stay (58 h 35 min v 34 h 36 min; P = 0.03) and hospital mortality (42.8% v 20.2%; P < 0.01).

CONCLUSION

Patients discharged from the ED to a general ward and subsequently to an ICU or SDU had a mortality that exceeded that of ED patients admitted directly to the ICU or SDU. Further investigations are warranted to explain this excess mortality and ascertain the extent of potential preventability.

Accessibility of the Australian population to an ICU, and of ICUs to each other

OBJECTIVE

To use a geographic information system to qualitatively and quantitatively illustrate the geospatial relationship of the Australian population to intensive care resources.

DESIGN, SETTING AND PARTICIPANTS

Intensive care unit data were sourced from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation critical care resources survey (2007-2008) and adult patient database (2002-2008), and postcode data (2006) from the Australian Bureau of Statistics. Remoteness was classified within remoteness categories and the Accessibility/Remoteness Index of Australia Plus. Distance was the difference between two postcode's centroids.

RESULTS

Ninety-one public ICUs were identified. Of these, 50 (54.9%) were in a major city, 24 (26.4%) were inner regional, 15 (16.5%) were outer regional, one (1.1%) was remote and one (1.1%) was very remote, compared with 64.2%, 20.8%, 11.7%, 1.9% and 1.4% of the population, respectively (P = 0.324). Median population distance to the closest ICU was 35.9 km and closest Level 3 ICU was 54.8 km. This varied by state/territory, ranging from 7.6 km to the closest ICU for the Australian Capital Territory to 161.7 km for Western Australia. Overall, 84.8% of the Australian population were 0-50 km from an ICU, 12.9% were 51-300km, 2.3% were 301-1500 km, and 0.01% were > 1500km. This varied among the states/territories. A Level 3 ICU was the closest ICU for 65.4% of the population, a Level 2 for 27.6% and a Level 1 for 7%. Median distance between any two ICUs was 21.1 km. Generally, the distance between Level 3 ICUs was shorter than the distance to a Level 1 or Level 2 ICU.

CONCLUSIONS

The distribution of Australian ICUs and the Australian population was similar. However, accessibility varied by state/territory.

Efficacy of Critical Incident Monitoring for Evaluating Disaster Medical Readiness and Response During the Sydney 2000 Olympic Games

Introduction:

Multiple casualty incidents (MCI) are infrequent events for medical systems. This renders audit and quality improvement of the medical responses difficult. Quality tools and use of such tools for improvement is necessary to ensure that the design of medical systems facilitates the best possible response to MCI.

Objective:

To describe the utility of incident reporting as a quality monitoring and improvement tool during the deployment of medical teams for mass gatherings and multiple casualty incidents.

Methods:

Voluntary and confidential reporting of incidents was provided by members of the disaster medical response teams during the period of disaster medical team deployment for the 2000 Sydney Olympic Games. Qualitative evaluations were conducted of reported incidents. The main outcome measures included the nature of incident and associated contributing factors, minimization factors, harm potential, and comparison with the post-deployment, cold debriefings.

Results:

A total of 53 incidents were reported. Management-based decisions, poor or non-existent protocols, and equipment and communicationrelated issues were the principal contributing factors. Eighty nine percent of the incidents were considered preventable. A potential for harm to patients and/or team members was documented in 58% of reports, of which 76% were likely to cause at least significant harm. Of equipment incidents, personal protective equipment (33%), medical equipment (27%), provision of equipment (22%), and communication equipment (17%) predominated. Personal protective equipment (50%) was reported as the most frequent occupational health and safety incident followed by fatigue (25%). Predeployment planning was the most important factor for future incident impact minimization.

Conclusions:

Incident monitoring was efficacious as a quality tool in identifying incident contributing factors. Incident monitoring allowed for greater systems evaluation. Further evaluation of this quality tool within different disaster settings is required.

Medical reviews before cardiac arrest, medical emergency call or unanticipated intensive care unit admission: their nature and impact on patient outcome

OBJECTIVE

To measure and describe the extent and consequences of documented medical patient reviews in the 24 hours before a cardiac arrest, medical emergency team (MET) call or an unanticipated intensive care unit admission ("event"), and the use of such reviews as a rapid response system performance measure.

DESIGN

Retrospective case-note and database review.

SETTING

Tertiary referral hospital, April-September, 2008.

PARTICIPANTS

Adult inpatients who had an event and a preceding hospital length of stay > 24 hours.

MAIN OUTCOME MEASURES

Hospital discharge status, ICU length of stay, not-for-resuscitation order.

RESULTS

443 patients had 575 events (6.1% cardiac arrests, 68.7% MET calls, 25.2% ICU admissions) in the study period. A documented medical review preceded 561 (97.6%) events. Patients whose review was a home team review (HTR; ie, from a general ward) only were older than those with a critical care review (CCR) (70.2 v 63.6 years; P < 0.01). A critical care discharge (CCD) or CCR preceded 39.5% and HTR only, 57.9% of events. A CCD preceded 25.7% of cardiac arrests, 32.4% of MET calls, and 29.0% unanticipated ICU admissions. Patients with a CCR or CCD had lower hospital mortality than those with an HTR only (27.3% v 41.7%; P < 0.01), and shorter median ICU length of stay (2 [interquartile range, 1-3] v 2 [interquartile range, 1-6] days; P = 0.04).

CONCLUSIONS

Medical reviews in the 24 hours before an adverse event are common. The type of medical review may influence patient outcome and thus may be a useful measure of rapid-response systems and critical care performance.

Baseline hospital performance and the impact of medical emergency teams: modelling vs. conventional subgroup analysis

BACKGROUND

To compare two approaches to the statistical analysis of the relationship between the baseline incidence of adverse events and the effect of medical emergency teams (METs).

METHODS

Using data from a cluster randomized controlled trial (the MERIT study), we analysed the relationship between the baseline incidence of adverse events and its change from baseline to the MET activation phase using quadratic modelling techniques. We compared the findings with those obtained with conventional subgroup analysis.

RESULTS

Using linear and quadratic modelling techniques, we found that each unit increase in the baseline incidence of adverse events in MET hospitals was associated with a 0.59 unit subsequent reduction in adverse events (95%CI: 0.33 to 0.86) after MET implementation and activation. This applied to cardiac arrests (0.74; 95%CI: 0.52 to 0.95), unplanned ICU admissions (0.56; 95%CI: 0.26 to 0.85) and unexpected deaths (0.68; 95%CI: 0.45 to 0.90). Control hospitals showed a similar reduction only for cardiac arrests (0.95; 95%CI: 0.56 to 1.32). Comparison using conventional subgroup analysis, on the other hand, detected no significant difference between MET and control hospitals.

CONCLUSIONS

Our study showed that, in the MERIT study, when there was dependence of treatment effect on baseline performance, an approach based on regression modelling helped illustrate the nature and magnitude of such dependence while sub-group analysis did not. The ability to assess the nature and magnitude of such dependence may have policy implications. Regression technique may thus prove useful in analysing data when there is a conditional treatment effect.

The Medical Emergency Team System and not-for-resuscitation orders: results from the MERIT study

OBJECTIVE

To examine NFR orders in relation to adverse events and emergency team calls in hospitals with or without a Medical Emergency Team (MET) system during the MERIT study.

METHOD

Within a cluster randomized controlled trial (the MERIT study), examining the effect of introducing a MET system, we recorded NFR orders in relation to adverse events and emergency team calls. We compared the proportion and rate of NFR orders issued in relation to "adverse events" and "adverse event-free emergency team calls" in hospitals with or without a MET system.

RESULTS

Information on NFR orders was available for 3650 patients who died, 1466 patients who had an unplanned ICU admission, 574 patients who suffered a cardiac arrest and 1529 patients who had a adverse event-free emergency team call. Close to 90% of deaths occurred in patients with a previously documented NFR order. Only approximately 4% of cardiac arrests had a previously documented NFR order. In patients with unplanned ICU admission, NFR orders were present in approximately 3% of cases. An NFR order was issued at the time of an "event" in 3.85% of cases in MET hospitals compared with 1.72% in control hospitals (OR=2.29; 95% CI: 1.31-4.01; p=0.005). This difference was mostly due to a greater proportion of patients being made NFR in MET hospitals at the time of a "adverse event-free" emergency team call (7.96% vs. 3.05%; OR=2.75; 95% CI: 0.97-7.80; p=0.048). The number of NFR orders issued at the time of a serious adverse event-free emergency team call was 10 times higher in MET hospitals (0.398 vs. 0.041 per 1000 admissions; weighted absolute risk difference: 0.49 (95% CI: 0.20-0.78; p=0.002). Multivariate models could only account for less than 50% of the variance in the issuing of NFR orders.

CONCLUSIONS

In a cohort of Australian hospitals, most deaths occurred in patients with a previously documented NFR order but NFR orders were uncommon before cardiac arrest calls or unplanned ICU admissions. During the conduct of a cluster randomised controlled trial, more NFR orders were issued by emergency teams in those hospitals that implemented a MET system than in control hospitals. MET allocation, teaching hospital status, number of hospital beds and metropolitan location could only explain less than 50% of variance in NFR orders.

Observational study of patients admitted to intensive care units in Australia and New Zealand after interhospital transfer

OBJECTIVE

To describe the demographics, illness categories and outcomes of adult intensive care unit patients who underwent interhospital transfer (IHT).

DESIGN

Retrospective review of data from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD), a binational intensive-care quality-assurance dataset.

PARTICIPANTS AND SETTING

332 009 patients from 125 Australian and New Zealand adult ICUs, who were aged 16 years or older, and had a known hospital and ICU source of admission between 1 January 1994 and 31 December 2003.

RESULTS

Tertiary ICUs contributed 47.9% of patients, metropolitan 20.9%, private 16.7% and rural/regional 14.5%. Patients admitted to an ICU after IHT had more severe illness, longer hospital stay, and a higher intubation rate, mortality and rate of discharge to another hospital. Over 10 years, the proportion of IHTs increased for rural/regional (R2=0.639; P=0.006) and tertiary (R2=0.703; P=0.002) hospitals, and for the diagnoses of sepsis (R2=0.877; P<0.001) and respiratory infection (R2=0.679, P=0.003); decreased for trauma (R2=0.612; P=0.007); and was associated with fewer ICU admissions after elective surgery (Beta=-1.47; 95% CI, -2.19 to -0.74; P<0.001) and from the operating theatre (Beta=-0.78; 95% CI, -1.46 to -0.1; P=0.03). IHT was most common during July-October and on Fridays and Saturdays. There were significant variations between Australian states and territories and New Zealand.

CONCLUSIONS

Patients admitted to an ICU after IHT have significant resource implications based on their severity of illness, hospital stay and mortality, and adversely affect ICU capacity for elective and operating theatre admissions. Regional differences and temporal trends have implications for planning of ICU resources and require ongoing surveillance.

Outcomes of patients admitted to tertiary intensive care units after interhospital transfer: comparison with patients admitted from emergency departments

OBJECTIVES

To compare outcomes of patients admitted to tertiary-level intensive care units after interhospital transfer (IHT) with those of similar patients admitted from the emergency department (ED).

DESIGN

Historical case-control study using data from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD), a quality-assurance dataset.

PARTICIPANTS AND SETTING

28882 patients aged 16 years or older admitted to an adult tertiary ICU in Australia or New Zealand between 1 January 1994 and 31 December 2003 with one of the eight most common diagnoses for IHT patients. Patients admitted directly to the ICU from another hospital (DIHT group) (n=9203) were matched by age, sex, APACHE II score and diagnosis with non-IHT patients admitted from the ED (ED group).

RESULTS

Hospital mortality was higher in the DIHT group than in the ED group for patients with a diagnosis of multiple trauma (11.0% v 5.1%; odds ratio [OR], 2.3; 95% CI, 1.6- 3.34), respiratory infection (28.1% v 19.1%; OR, 1.66; 95% CI, 1.34-2.05), sepsis (38.7% v 28.7%; OR, 1.57; 95% CI, 1.34-1.83), intracranial haemorrhage (49.9% v 42.6%; OR, 1.34; 95% CI, 1.14-1.58), head injury alone (16.9% v 13.7%; OR, 1.28; 95% CI, 1.01-1.62), and cardiac arrest (59.3% v 53.2%; OR, 1.28; 95% CI, 1.06-1.56), but not overdose (3.9% v 3.6%; OR, 1.09; 95% CI, 0.72-1.67) or chronic obstructive pulmonary disease (19.8% v 22.5%; OR, 0.85; 95% CI, 0.63-1.15). Overall, the DIHT group had a higher intubation rate, longer ICU stay and higher rate of discharge to another hospital.

CONCLUSIONS

Patients admitted to an ICU from another hospital have higher hospital mortality and longer stay than those admitted from the ED, with the differences varying between diagnoses. These differences are important considerations for resource allocation and triage, and as a measure of quality.

The effectiveness of implementation of the medical emergency team (MET) system and factors associated with use during the MERIT study

OBJECTIVE

The potential of the medical emergency team (MET) system to reduce adverse events may depend on the effectiveness of its implementation. We aimed to evaluate the effectiveness of the implementation of the MET system during the MERIT (Medical Early Response, Intervention and Therapy) study and to determine factors associated with the level of MET system utilisation.

METHODS

Surveys were conducted on the nursing staff from the general adult wards of all 12 MERIT study intervention hospitals after the 4-month implementation period and again after the 6-month study period. Hospital level variables were assessed for their correlation with MET utilisation. We measured awareness and understanding of the MET system, attendance at a MET education session, knowledge of the activation criteria, intention to call the MET, attitude to the MET system and the level of MET utilisation.

RESULTS

Across the 12 intervention hospitals, a median of 85.6% (interquartile range, 81.3%-88.8%) of MET activations were not related to a cardiac arrest or death. This measure of MET system utilisation varied significantly across the 12 hospitals (P = 0.002), and was significantly associated with knowledge of the activation criteria (P = 0.048), understanding of the purpose of the MET system (P = 0.01), perceptions of the hospital's readiness for a change in the way care was provided (P = 0.004), and an overall positive attitude to the MET system (P = 0.003).

CONCLUSIONS

Measures of the process of implementation of the MET system were significantly associated with the level of MET system utilisation.

REDUCING TIME TO URGENT SURGERY BY TRANSPORTING RESOURCES TO THE TRAUMA PATIENT

BACKGROUND

Time to definitive trauma care directly influences patient survival. Patient transport (retrieval) services are essential for the transportation of remotely located trauma patients to a major trauma centre. Trauma surgical expertise can potentially be combined with the usual retrieval response (surgically supported response) and delivered to the patient before patient transportation. We identified the frequency and circumstances of such surgically supported retrievals.

METHODS

Retrospective review of trauma patients transported by the NRMA CareFlight, New South Wales Medical Retrieval Service, Australia, from 1999 to 2003, identifying patients who had a surgically supported retrieval response and an urgent surgical procedure carried out before patient transportation to an major trauma centre.

RESULTS

Seven hundred and forty-nine trauma interhospital patient transfers were identified of which 511 (68%) were categorized as urgent and 64% of which were rural based. Three (0.4%) patients had a surgically supported retrieval response and had an urgent surgical procedure carried out before patient transportation. All patients benefited from that early surgical intervention.

CONCLUSION

A surgically supported retrieval response allows for the more timely delivery of urgent surgical care. Patients can potentially benefit from such a response. There are, however, important operational considerations in providing a surgically supported retrieval response.

The objective medical emergency team activation criteria: a case-control study

OBJECTIVE

To evaluate the ability of pre-defined clinical criteria to identify patients who subsequently suffer cardiac arrest, unplanned intensive care unit admission or unexpected death; to determine the ability of modified criteria to identify these patients.

DESIGN

Nested, matched case-control study.

SETTING

Seven Australian public hospitals.

PATIENTS AND PARTICIPANTS

Four hundred and fifty cases and 520 controls matched for age, sex, hospital, and hospital ward.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Highest and lowest respiratory and heart rates, lowest systolic blood pressure, presence of threatened airway, seizures or decrease in Glasgow Coma Scale score of greater than two points and incidence of the three adverse events were measured. Combining a heart rate greater than 140, respiratory rate greater than 36, a systolic blood pressure less than 90 mmHg and a greater than two point reduction in the Glasgow Coma Scale identified adverse events with a sensitivity of 49.1% (44.4-53.8%), specificity of 93.7% (91.2-95.6%), and positive predictive value of 9.8% (8.7-11.1%). Adding threatened airway, seizures, low respiratory rate and low heart rate did not substantially improve sensitivity (50.4%; 45.7-55.2%). After modifying the cut-off values for respiratory rate, heart rate and systolic blood pressure, the best achievable positive predictive value remained below 16%.

CONCLUSIONS

In combination, the respiratory rate, heart rate, systolic blood pressure, and level of consciousness identify patients at risk of cardiac arrest, unplanned intensive care admission or unexpected death with high specificity; however the sensitivity and positive predictive value are relatively low, even after modification of the activation criteria cut-off values.

Awareness in retrieval medicine

Awareness is the spontaneous recall of an event(s) that occurred during general anaesthesia and surgery. The incidence of awareness is approximately 0.2% of cases where neuromuscular blockers are used and half that where they are omitted. The majority of data relating to awareness is from anaesthetic practice. We report a case of awareness associated with an out-of-hospital transportation of a critically ill patient requiring a medical escort (retrieval). We discuss the risk factors associated with awareness during retrieval, in particular the trend toward excessive administration of neuromuscular blockers, and the unique challenges for the prevention of awareness within the retrieval environment.