The impact of frailty and rapid response team activation on patients admitted to the intensive care unit: A case-control matched, observational, single-centre cohort study

BACKGROUND

Frailty is a multi-dimensional syndrome associated with mortality and adverse outcomes in patients admitted to the intensive care unit (ICU). Further investigation is warranted to explore the interplay among factors such as frailty, clinical deterioration triggering a medical emergency team (MET) review, and outcomes following admission to the ICU.

METHODS

Single-centre, retrospective observational case-control study of adult patients (>18 years) admitted to a medical-surgical ICU with (cases) or without (controls) a preceding MET review between 4 h and 14 days prior. Matching was performed for age, ICU admission diagnosis, Acute Physiology and Chronic Health Evaluation III (APACHE III) score and the 8-point Clinical Frailty Scale (CFS). Cox proportional hazard regression modelling was performed to determine associations with 30-day mortality after admission to ICU.

RESULTS

A total of 2314 matched admissions were analysed. Compared to non-frail patients (CFS 1-4), mortality was higher in all frail patients (CFS 5-8), at 31% vs. 13%, and in frail patients admitted after MET review at 33%. After adjusting for age, APACHE, antecedent MET review and CFS in the Cox regression, mortality hazard ratio increased by 26% per CFS point and by 3% per APACHE III point, while a MET review was not an independent predictor. Limitations of medical treatment occurred in 30% of frail patients, either with or without a MET antecedent, and this was five times higher compared to non-frail patients.

CONCLUSION

Frail patients admitted to ICU have a high short-term mortality. An antecedent MET event was associated with increased mortality but did not independently predict short-term survival when adjusting for confounding factors. The intrinsic significance of frailty should be primarily considered during MET review of frail patients. This study suggests that routine frailty assessment of hospitalised patients would be helpful to set goals of care when admission to ICU could be considered.

Patient outcomes following medical emergency team review on general wards: Development of predictive models

AIM

To develop and internally validate risk prediction models for subsequent clinical deterioration, unplanned ICU admission and death among ward patients following medical emergency team (MET) review.

DESIGN

A retrospective cohort study of 1500 patients who remained on a general ward following MET review at an Australian quaternary hospital.

METHOD

Logistic regression was used to model (1) subsequent MET review within 48 h, (2) unplanned ICU admission within 48 h and (3) hospital mortality. Models included demographic, clinical and illness severity variables. Model performance was evaluated using discrimination and calibration with optimism-corrected bootstrapped estimates. Findings are reported using the TRIPOD guideline for multivariable prediction models for prognosis or diagnosis. There was no patient or public involvement in the development and conduct of this study.

RESULTS

Within 48 h of index MET review, 8.3% (n = 125) of patients had a subsequent MET review, 7.2% (n = 108) had an unplanned ICU admission and in-hospital mortality was 16% (n = 240). From clinically preselected predictors, models retained age, sex, comorbidity, resuscitation limitation, acuity-dependency profile, MET activation triggers and whether the patient was within 24 h of hospital admission, ICU discharge or surgery. Models for subsequent MET review, unplanned ICU admission, and death had adequate accuracy in development and bootstrapped validation samples.

CONCLUSION

Patients requiring MET review demonstrate complex clinical characteristics and the majority remain on the ward after review for deterioration. A risk score could be used to identify patients at risk of poor outcomes after MET review and support general ward clinical decision-making.

RELEVANCE TO CLINICAL PRACTICE

Our risk calculator estimates risk for patient outcomes following MET review using clinical data available at the bedside. Future validation and implementation could support evidence-informed team communication and patient placement decisions.

A Delphi study to obtain consensus on medical emergency team (MET) stand-down decision making

AIM

A medical emergency team (MET) stand-down decision is the decision to end a MET response and hand responsibility for the patient back to ward staff for ongoing management. Little research has explored this decision. This study aimed to obtain expert consensus on the essential elements required to make optimal MET call stand-down decisions and the communication required before MET departure.

DESIGN

A Delphi design was utilised.

METHODS

An expert panel of 10 members were recruited based on their expert knowledge and recent clinical MET responder experience in acute hospital settings. Participants were emailed a consent form and an electronic interactive PDF for each survey. Two rounds were conducted with no attrition between rounds. The CREDES guidance on conducting and reporting Delphi studies was used to report this study.

RESULTS

Consensus by an expert panel of 10 MET responders generated essential elements of MET stand-down decisions. Essential elements comprised of two steps: (1) the stand-down decision that was influenced by both the patient situation and the ward/organisational context; and (2) the communication required before actioning stand-down. Communication after the decision required both verbal discussions and written documentation to hand over patient responsibility. Specific patient information, a management plan and an escalation plan were considered essential.

CONCLUSION

The Delphi surveys reached consensus on the actions and communication required to stand down a MET call. Passing responsibility back to ward staff after a MET call requires both patient and ward safety assessments, and a clearly articulated patient plan for ward staff. Observation of MET call stand-down decision-making is required to validate the essential elements.

IMPLICATION FOR THE PROFESSION AND PATIENT/OR PATIENT CARE

In specifying the essential elements, this study offers clinical and MET staff a process to support the handing over of clinical responsibility from the MET to the ward staff, and clarification of management plans in order to reduce repeat MET calls and improve patient outcomes.

IMPACT

Minimal research has been focussed on the decision to hand responsibility back to ward staff so the MET may leave the ward with safety plan in place. This study provided expert consensus to optimise MET stand-down decision-making and the ultimate decision to end a MET call. Communication of agreed patient treatment and escalation plans is recommended before leaving the ward. This study can be used as a checklist for MET responder staff making these decisions and ward staff responsible for post-MET call care. The aim being to reduce the likelihood of potentially preventable repeat deterioration in the MET patient population.

REPORTING METHOD

The CREDES guidance on conducting and reporting Delphi studies.

PATIENT OR PUBLIC CONTRIBUTION

None.

Safety and Effectiveness of Intensive Treatments Administered Outside the Intensive Care Unit to Hematological Critically Ill Patients: An Intensive Care without Walls Trial

Historically, the admission of hematological patients in the ICU shortly after the start of a critical illness is associated with better survival rates. Early intensive interventions administered by MET could play a role in the management of hematological critically ill patients, eventually reducing the ICU admission rate. In this retrospective and monocentric study, we evaluate the safety and effectiveness of intensive treatments administered by the MET in a medical ward frame. The administered interventions were mainly helmet CPAP and pharmacological cardiovascular support. Frequent reassessment by the MET at least every 8 to 12 h was guaranteed. We analyzed data from 133 hematological patients who required MET intervention. In-hospital mortality was 38%; mortality does not increase in patients not immediately transferred to the ICU. Only three patients died without a former admission to the ICU; in these cases, mortality was not related to the acute illness. Moreover, 37% of patients overcame the critical episode in the hematological ward. Higher SOFA and MEWS scores were associated with a worse survival rate, while neutropenia and pharmacological immunosuppression were not. The MET approach seems to be safe and effective. SOFA and MEWS were confirmed to be effective tools for prognostication.

Modifications to rapid response team (medical emergency team) activation criteria and its impact on patient safety

BACKGROUND

Modifications to rapid response team (RRT) activation criteria occur commonly in Australian hospitals without evidence to define their use.

AIMS

To evaluate the effectiveness of RRT activation criteria modifications in preventing RRT activation and differences in adverse events associated with treatment delays caused by modifications.

METHODS

A prospective chart audit of hospital patients with RRT activation criteria modifications admitted during a 12-month period in a large regional hospital in Toowoomba, Australia. The incidence of RRT activation criteria modifications, RRT activations and rates of adverse events following criteria modifications were investigated. Adverse events were defined as a delayed treatment on the ward, unplanned intensive care unit admission, cardiac arrest and unexpected death. Differences in patient outcomes among medical and surgical patients were also investigated.

RESULTS

A total of 271 patients out of 4009 admitted patients had modifications to their RRT activation criteria. There was no difference in rates of RRT activation in patients with modified criteria compared with patients with unmodified criteria (P = 0.37). In patients with RRT activation criteria modifications, rates of adverse events were higher in patients who met their modified RRT criteria (93.3%) compared with those who did not meet modified RRT criteria (3.8%; P < 0.001). Additionally, in patients with modifications, rates of adverse events were higher in medical patients (27.6%; n = 50) compared with surgical patients (15.6%; n = 14; P = 0.03).

CONCLUSIONS

The results strongly suggest that RRT criteria modification is associated with no difference in rates of RRT activation and with detrimental impacts on patient safety, particularly in medical patients.

Dosage and clinical outcomes of medical emergency team and conventional referral mediated unplanned intensive care admissions

Background: Unplanned intensive care unit (ICU) admission occurs via activation of medical emergency team (MET) and conventional ICU referral (CIR), i.e., ICU consultation. We aimed to compare the dosage, association with unplanned ICU admissions and hospital mortality between MET and CIR systems. Methods: We performed a retrospective, single centre observational study on unplanned ICU admissions from hospital wards between July 2017 and June 2018. We evaluated the dosage (expressed per 1000 admissions) and association of CIR and MET system with unplanned ICU admission using Chi-square test. The relationship (unadjusted and adjusted to Australia and New Zealand risk of death (ANZROD) and lead time) between unplanned ICU admission pathway (MET vs CIR) and hospital mortality was tested by binary logistic regression analysis [Odds ratio (OR) with 95% confidence interval (CI)]. Results: Out of 38,628 patients hospitalised, 679 had unplanned ICU admission (2%) with an ICU admission rate of 18 per 1000 ward admissions. There were 2153 MET and 453 CIR activations, producing a dosage of 56 and 12 per 1000 admissions, respectively. Higher unplanned ICU admission was significantly associated with CIR compared to MET activation (324/453 (71.5%) vs 355/2153 (16.5%) p < 0.001). On binary logistic regression, MET system was significantly associated with higher hospital mortality on unadjusted analysis (OR 1.65 (95% CI: 1.09-2.48) p = 0.02) but not after adjustment with ANZROD and lead time (OR 1.15 (95% CI: 0.71-1.86), p = 0.58). Conclusions: Compared to CIR, MET system had higher dosage but lower frequency of unplanned ICU admissions and lacked independent association with hospital mortality.

Implementation of a non-intensive-care unit medical emergency team improves failure to rescue rates in cardiac surgery patients

OBJECTIVE

Failure to rescue (FTR) is an emerging measure in cardiac surgery, defined as mortality after a postoperative complication. We hypothesized that establishing a medical emergency team (MET) reduced rates of FTR in adults undergoing cardiac surgery.

METHODS

All patients (N = 11,218) undergoing a The Society of Thoracic Surgeons index operation at our center (1994-2018) were stratified by pre-MET or MET era based on the 2009 institutional implementation of a MET to respond to clinical decompensation in non-intensive-care patients. Patients missing The Society of Thoracic Surgeons predicted risk of mortality were excluded from all cohorts. Risk adjusted multivariable regression analyzed the association of postoperative complications, operative mortality, and FTR by era. Nearest neighbor propensity score matching utilizing patients' The Society of Thoracic Surgeons predicted risk of mortality was performed to create balanced control and exposure groups for secondary subgroup analysis.

RESULTS

In the risk-adjusted multivariable analysis, surgery during the MET era was associated with decreased mortality (odds ratio [OR], 0.51; 95% CI, 0.45-0.77; P < .001), postoperative renal failure (OR, 0.57; 95% CI, 0.46-0.70; P < .001), reoperation (OR, 0.75; 95% CI, 0.59-0.95; P = .017), and deep sternal wound infection (OR, 0.16; 95% CI, 0.04-0.45; P = .002). Surgery performed during the MET era was associated with a decreased rate of FTR in the risk-adjusted analysis (OR, 0.46; 95% CI, 0.34-0.70; P < .001).

CONCLUSIONS

The development of an institutional MET program was associated with a decrease in major complications and FTR. These findings support the development of MET programs to improve FTR after cardiac surgery.

Review article: Use of the Team Emergency Assessment Measure in the rating of emergency teams' non-technical skills: A mapping review

The present study aims to explore the utility of the Team Emergency Assessment Measure (TEAM) in relation to the enhancement of emergency team non-technical skills based on research conducted over the last decade. In this mapping review, a citation mining process identified 22 primary studies for inclusion, published between 2012 and 2022. It provides outcome data on emergency teams' non-technical skills following team training and/or real-life patient emergencies. Emergency team studies related to resuscitation teams (adult, paediatric, newborn and obstetric cases) and medical emergency team (MET) management of patient deterioration. Team performance ratings varied, ranging from approximately 90% for experienced clinical teams down to 38% for students. Statistically significant improvements in performance were notable following training and/or repeated practice. Validity evidence, across 11 studies that provided change data described positive learning outcomes and moderate intervention effects. However, according to Kirkpatrick's model of educational evaluation the studies were limited to professional development phases of learning and immediate post-training assessments rather than care quality improvement. The review highlights a lack of studies evidencing quality improvement or clinical impact such as change of patient care practice or health service performance. There is a need to conduct well-designed studies that explore both technical and non-technical skills of resuscitation teams and METs. Currently, non-technical skills training and repeated performance evaluations using the TEAM contribute immensely to the proficiency of emergency teams.

Piloting a Nurse-Led Critical Care Outreach Service to Pre-Empt Medical Emergency Team Calls and Facilitate Staff Learning

A nurse-led critical care outreach service (NLCCOS) can support staff education and decision making in the wards, managing at-risk patients with ward nurses to avoid further deterioration. We aimed to investigate the characteristics of patients identified as at-risk, the types of treatments they required to prevent deterioration, the education initiated by the NLCCOS, and the perceived experiences of ward nurses. This prospective observational pilot study using mixed methods took place in one medical and one surgical ward at a university hospital in Denmark. Participants were patients nominated as at-risk by head nurses in each ward, the ward nurses, and nurses from the NLCCOS. In total, 100 patients were reviewed, 51 medical and 49 surgical patients, over a six-month period. Most patients (70%) visited by the NLCCOS had a compromised respiratory status, and ward nurses received teaching and advice regarding interventions. Sixty-one surveys were collected from ward nurses on their learning experience. Over 90% (n = 55) of nurses believed they had learned from, and were more confident with, managing patients following the experience. The main educational areas were respiratory therapy, invasive procedures, medications, and benefits of mobilization. Further research needs to measure the impact of the intervention on patient outcomes and MET call frequency over time in larger samples.

Contextual factors influencing patients' experiences of acute deterioration and medical emergency team (MET) encounter: A grounded theory study

AIM

This paper explores the personal, social and structural factors that influence patients' experiences of acute deterioration and medical emergency team (MET) encounter.

BACKGROUND

Patient experience is recognized as a means of assessing healthcare delivery with a positive experience being linked to high-quality healthcare, improved patient safety and reduced length of stay. The experience of acute deterioration is unique, extensive and complex. However, little is known about this experience from the patient's perspective.

DESIGN

Constructivist grounded theory, informed by Kathy Charmaz, was used to explore the personal, social and structural factors that influence patients' experiences of acute deterioration and MET encounter.

METHODS

Using a semi-structured interview guide, in-depth individual interviews were conducted with 27 patients from three healthcare services in Victoria, Australia. Data were collected over a 12-month period from 2018 to 2019. Interview data were analysed using grounded theory processes.

FINDINGS

Contextual factors exert a powerful influence on patients' experiences of acute deterioration and MET encounter. The most significant factors identified include patients' expectations and illness perception, relationship with healthcare professionals during MET call and past experiences of acute illness. The expectations and perceptions patients had about their disease can condition their overall experience. Healthcare professional-patient interactions can significantly impact quality of care, patient experience and recovery. Patients' experiences of illness and healthcare can impact a person's future health-seeking behaviour and health status.

CONCLUSION

Patients' actions and processes about their experiences of acute deterioration and MET encounter are the result of the complex interface of contextual factors.

IMPACT

The findings from this study have highlighted the need for revised protocols for screening and management of patients who experience acute deterioration.

Rapid response teams-how and who? A protocol for a randomised clinical trial evaluating the composition of the efferent limb of the rapid response system

BACKGROUND

Many patients experiencing deterioration have documented deviation of vital signs prior to the deterioration event. Increasing focus on these patients led to the rapid response systems and their configuration with afferent and efferent limbs. The two most prevalent team constellations in the efferent limb are the medical emergency team (MET), usually led by a doctor, and the critical care outreach team (CCOT), usually led by a nurse. The two constellations have not previously been examined in a comparative clinical trial.

METHODS

This is a single centre non-inferiority randomised controlled trial of MET vs CCOT. All patients will be randomised at the time of the call. The intervention group will be the critical care outreach team. The primary outcome is mortality at 30 days and the occurrence of serious adverse events. All patients will be followed for 90 days. We aim to detect or reject a change of 7% in mortality whilst accepting a type I error of 5 and type II error of 20, using a sample size of maximum of 2000 individual patients.

DISCUSSION

There is evidence supporting a benefit for the patient when using rapid response systems; however, earlier randomised studies are marked by cross-contamination and selection bias. Previous studies have primarily examined the effect of RRS on hospital cardiac arrests (IHCA) and mortality. Our study will be examining the effect on intensive care unit admissions as well as the ICHA and mortality.

CONCLUSION

This study may highlight potential benefits of specific configurations of rapid response systems and their impact on safety outcomes.

Features, risk factors, and outcomes of older internal medicine patients triggering a medical emergency team call

BACKGROUND

Information about the epidemiology of older Internal Medicine patients receiving medical emergency team (MET) calls is limited. We assessed the prevalence, characteristics, risk factors, and outcomes of this vulnerable group.

METHODS

Internal Medicine patients aged >75 years who were admitted via the Emergency Department to a tertiary hospital between January 2015 to December 2018 and who activated a MET call were compared to patients without MET call activation during the same time period. Outcome measures included management post-MET call, Intensive Care Unit (ICU) admission rates, discharge disposition, length of hospital stays (LOS), and in-patient mortality.

RESULTS

There were 10,803 Internal Medical admissions involving 10,423 patients; median age 85 (IQR 81-89) years. Of these, 995 (10%) patients received at least one MET call. MET call patients had greater physiological instability in the Emergency Department and higher median Charlson comorbidity index values (2, IQR 1-3 vs. 1, IQR 0-2; p < .0001) than non-MET call patients. Overall, 10% of MET call patients were admitted to ICU. MET patients had a longer median length of stay (9 [IQR 5-14] vs. 4 days [IQR 2-7]; p < .001) and higher in-hospital mortality (29% vs. 7%; p < .001). However, mortality of MET call patients without treatment limitations was 48/357 (13%).

CONCLUSION

One in ten Internal Medicine patients aged >75 years and admitted via ED had a MET call. Physiological instability in ED and comorbidities were key risk factors. Mortality in MET patients approached 30%. These data can help predict at-risk patients for improving goals of care and pre-MET interventions.

Implementation of a rapid response system at an isolated radiotherapy facility through simulation training

A rapid response system is required in a radiotherapy department for patients experiencing a critical event when access to an emergency department is poor due to geographic location and the patient is immobilised with a fixation device. We, therefore, rebuilt the response system and tested it through onsite simulations. A multidisciplinary core group was created and onsite simulations were conducted using a Plan-Do-Study-Act cycle. We identified the important characteristics of our facility, including its distance from the emergency department; the presence of many staff with little direct contact with patients; the treatment room environment and patient fixation with radiotherapy equipment. We also examined processes in each phase of the emergency response: detecting an emergency, calling the medical emergency team (MET), MET transportation to the site and on-site response and patient transportation to the emergency department. The protocol was modified, and equipment was updated. On-site simulations were held with and without explanation of the protocol and training scenario in advance. The time for the MET to arrive at the site during a 2017 simulation prior to the present project was 7 min, whereas the time to arrive after the first simulation session was shortened to 5 min and was then shortened further to 4 min in the second session, despite no prior explanation of the situation. A multidisciplinary project for emergency response with on-site simulations was conducted at an isolated radiation facility. A carefully planned emergency response is important not only in heavy ion therapy facilities but also in other departments and facilities that do not have easy access to hospital emergency departments.

Comparison of the National Early Warning Scores and Rapid Emergency Medicine Scores with the APACHE II Scores as a Prediction of Mortality in Patients with Medical Emergency Team Activation: a Single-centre Retrospective Cohort Study

Introduction

The medical emergency team enables the limitation of patients’ progression to critical illness in the general ward. The early warning scoring system (EWS) is one of the criteria for medical emergency team activation; however, it is not a valid criterion to predict the prognosis of patients with MET activation.

Aim

In this study, the National Early Warning Score (NEWS) and Rapid Emergency Medicine Score (REMS) was compared with that of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in predicting the prognosis of patients who had been treated a medical emergency team.

Material and Methods

In this single-centre retrospective cohort study, patients treated by a medical emergency team between April 2013 and March 2019 and the 28-day prognosis of MET-activated patients were assessed using APACHE II, NEWS, and REMS.

Results

Of the 196 patients enrolled, 152 (77.5%) were men, and 44 (22.5%) were women. Their median age was 68 years (interquartile range: 57-76 years). The most common cause of medical emergency team activation was respiratory failure (43.4%). Univariate analysis showed that APACHE II score, NEWS, and REMS were associated with 28-day prognostic mortality. There was no significant difference in the area under the receiver operating characteristic curve of APACHE II (0.76), NEWS (0.67), and REMS (0.70); however, the sensitivity of NEWS (0.70) was superior to that of REMS (0.47).

Conclusion

NEWS is a more sensitive screening tool like APACHE II than REMS for predicting the prognosis of patients with medical emergency team activation. However, because the accuracy of NEWS was not sufficient compared with that of APACHE II score, it is necessary to develop a screening tool with higher sensitivity and accuracy that can be easily calculated at the bedside in the general ward.

Epidemiology and Prognostic Significance of Rapid Response System Activation in Patients Undergoing Liver Transplantation

Patients undergoing liver transplantation have a high risk of perioperative clinical deterioration. The Rapid Response System is an intensive care unit-based approach for the early recognition and management of hospitalized patients identified as high-risk for clinical deterioration by a medical emergency team (MET). The etiology and prognostic significance of clinical deterioration events is poorly understood in liver transplant patients. We conducted a cohort study of 381 consecutive adult liver transplant recipients from a prospectively collected transplant database (2011–2017). Medical records identified patients who received MET activation pre- and post-transplantation. MET activation was recorded in 131 (34%) patients, with 266 MET activations in total. The commonest triggers for MET activation were tachypnea and hypotension pre-transplantation, and tachycardia post-transplantation. In multivariable analysis, female sex, increasing Model for End-Stage Liver Disease score and hepatorenal syndrome were independently associated with MET activation. The unplanned intensive care unit admission rate following MET activation was 24.1%. Inpatient mortality was 4.2% and did not differ by MET activation status; however, patients requiring MET activation had significantly longer intensive care unit and hospital length of stay and were more likely to require inpatient rehabilitation. In conclusion, liver transplant patients with perioperative complications requiring MET activation represent a high-risk group with increased morbidity and length of stay.

Cost-effectiveness of a quality improvement project, including simulation-based training, on reducing door-to-needle times in stroke thrombolysis

BACKGROUND

Rapid revascularisation in acute ischaemic stroke is crucial to reduce its total burden including societal costs. A quality improvement (QI) project that included streamlining the stroke care pathway and simulation-based training was followed by a significant reduction in median door-to-needle time (27 to 13 min) and improved patient outcomes after stroke thrombolysis at our centre. Here, we present a retrospective cost-effectiveness analysis of the QI project.

METHODS

Costs for implementing and sustaining QI were assessed using recognised frameworks for economic evaluations. Effectiveness was calculated from previously published outcome measures. Cost-effectiveness was presented as incremental cost-effectiveness ratios including costs per minute door-to-needle time reduction per patient, and costs per averted death in the 13-month post-intervention period. We also estimated incremental cost-effectiveness ratios for a projected 5-year post-intervention period and for varying numbers of patients treated with thrombolysis. Furthermore, we performed a sensitivity analysis including and excluding costs of unpaid time.

RESULTS

All costs including fixed costs for implementing the QI project totalled US$44 802, while monthly costs were US$2141. We calculated a mean reduction in door-to-needle time of 13.1 min per patient and 6.36 annual averted deaths. Across different scenarios, the estimated costs per minute reduction in door-to-needle time per patient ranged from US$13 to US$29, and the estimated costs per averted death ranged from US$4679 to US$10 543.

CONCLUSIONS

We have shown that a QI project aiming to improve stroke thrombolysis treatment at our centre can be implemented and sustained at a relatively low cost with increasing cost-effectiveness over time. Our work builds on the emerging theory and practice for economic evaluations in QI projects and simulation-based training. The presented cost-effectiveness data might help guide healthcare leaders planning similar interventions.

Identifying teamwork-related needs of the medical emergency team: Nurses' perspectives

BACKGROUND

The role of medical emergency team (MET) in managing deteriorating patients and enhancing patient safety is greatly affected by teamwork.

AIMS

To identify teamwork-related needs of the MET from MET nurses' perspectives. To assess the associations between MET nurses' perceptions of teamwork and their work experience and education.

STUDY DESIGN

A quantitative, descriptive correlational design.

METHODS

Registered intensive care unit (ICU) nurses (n = 50) who were members of the MET in an acute tertiary care hospital answered a modified version of the team assessment questionnaire in 2017. Data were analysed using descriptive statistics, the Kruskal-Wallis test, and the univariate analysis of variance method. The reporting of this study adheres to the strengthening the reporting of observational studies (STROBE) guidelines.

RESULTS

Participants showed least agreement with the items presenting leadership skills (mean = 2.6, SD = 0.68). Approximately 50% nurses disagreed that the MET had adequate resources, training, and skills. The majority of nurses (80%) felt that their responsibilities as a MET member interfered with taking care of their own ICU patients. Many nurses (64%) felt that they did not have a voice in MET's decision-making process. Approximately 50% nurses felt that they were not recognized for their individual contribution, and they were uncertain regarding MET's policies for dealing with conflicts. The amounts of MET nurses' work experience and education were associated with MET skills and function, respectively.

CONCLUSION

Key teamwork elements of the MET that need improvements include decision-making and conflict resolution skills, valuing team members, and team leadership. Practicing shared mental models, implementing the TeamSTEPPS curricula at hospitals for training ICU nurses, and simulation-based team-training programmes may be beneficial in improving teamwork of MET members.

RELEVANCE TO CLINICAL PRACTICE

This study revealed key teamwork elements of the MET that need improvements. Our findings may contribute to improve teamwork, thereby optimizing MET function, and enhancing patient outcomes.

Validation of National Early Warning Score for predicting 30-day mortality after rapid response system activation in Japan

Aim

Although rapid response systems (RRS) are used to prevent adverse events, Japan reportedly has low activation rates and high mortality rates. The National Early Warning Score (NEWS) could provide a solution, but it has not been validated in Japan. We aimed to validate NEWS for Japanese patients.

Methods

This retrospective observational study included data of 2,255 adult patients from 33 facilities registered in the In‐Hospital Emergency Registry in Japan between January 2014 and March 2018. The primary evaluated outcome was mortality rate 30 days after RRS activation. Accuracy of NEWS was analyzed with the correlation coefficient and area under the receiver operating characteristic curve. Prediction weights of NEWS parameters were then analyzed using multiple logistic regression and a machine learning method, classification and regression trees.

Results

The correlation coefficient of NEWS for 30‐day mortality rate was 0.95 (95% confidence interval [CI], 0.88–0.98) and the area under the receiver operating characteristic curve was 0.668 (95% CI, 0.642–0.693). Sensitivity and specificity values with a cut‐off score of 7 were 89.8% and 45.1%, respectively. Regarding prediction values of each parameter, oxygen saturation showed the highest odds ratio of 1.36 (95% CI, 1.25–1.48), followed by altered mental status 1.23 (95% CI, 1.14–1.32), heart rate 1.21 (95% CI, 1.09–1.34), systolic blood pressure 1.12 (95% CI, 1.04–1.22), and respiratory rate 1.03 (95% CI, 1.05–1.26). Body temperature and oxygen supplementation were not significantly associated. Classification and regression trees showed oxygen saturation as the most heavily weighted parameter, followed by altered mental status and respiratory rate.

Conclusions

National Early Warning Score could stratify 30‐day mortality risk following RRS activation in Japanese patients.

In-hospital cardiac arrest and preceding National Early Warning Score (NEWS): A retrospective case-control study

We aimed to describe and evaluate the National Early Warning Score (NEWS) in the 24 hours preceding an in-hospital cardiac arrest among general somatic ward patients.The 24 hours preceding the in-hospital cardiac arrest were divided into four timespans and analysed by a medical record review of 127:254 matched case-control patients. The median NEWS ranged from 3 (2-6) to 6 (3-9) points for cases vs 1 (0-3) to 1 (0-3) point for controls. The proportion of cases ranged from 23-45% at high risk vs 3-6% for controls. The NEWS high-risk category was associated with an increase of 3.17 (95% confidence interval (CI) 1.66-6.04) to 4.43 (95% CI 2.56-7.67) in odds of in-hospital cardiac arrest compared to the low-risk category.NEWS, with its intuitive and for healthcare staff easy to interpret risk classification, is suitable for discriminating deteriorating patients with major deviating vital signs scoring high risk on NEWS.

Rapid response team nurses' attitudes and barriers to the rapid response system: A multicentre survey

BACKGROUND

Despite wide implementation of rapid response teams (RRTs), no published data exist on RRT nurses' attitudes and barriers to the rapid response system (RRS).

METHODS

We piloted a 5-point Likert-type scale questionnaire among all Finnish university hospitals' RRT nurses with optional open-ended comments. The impact of more frequent RRT participation was further investigated.

RESULTS

The response rate was 46% (n = 176/379, 34%-93% between hospitals). The respondents median experience on a RRT was three years (0.8-5) and median participation was two (1-5) RRT activations per month. Over 90% of the RRT nurses felt that RRS prevented cardiac arrests and improved patient safety. Nurses with five or more RRT activations/month believed their critical care skills had improved through these duties (94% vs 71%, P = .001), considered their RRT work meaningful (94% vs 76%, P = .005) and wanted to continue as RRT nurses (91% vs 74%, P = .015) more often than nurses with less than five RRT activations/month. In addition to the infrequent RRT participation, further negative experiences with RRS among the RRT nurses included feeling overworked (68%) or undercompensated (94%) for the RRT duties and conflicts between RRT and ward doctors (25%).

CONCLUSION

RRT nurses consider their work important and believe it fosters improved critical care skills; these beliefs are emphasized among those with more frequent RRT participation. Infrequent RRT participation, feeling overworked and/or undercompensated and conflicts between RRT and ward doctors may present barriers for successful RRS among RRT nurses.

'Code-95' rapid response calls for patients under airborne precautions in the COVID-19-era: a cross-sectional survey of healthcare worker perceptions

BACKGROUND

To allow better allocation of staff and resources, rapid response teams attending to acutely deteriorating or aggressive patients with suspected or confirmed COVID-19 infection were pre-warned with the announcement of 'Code-95' with calls.

AIM

To assess healthcare worker (HCW) perspectives on pre-warning rapid response calls (RRC) with 'Code-95' in announcements when attending to deteriorating or aggressive patients with suspected/confirmed COVID-19 infection.

METHODS

Design: prospective cross-sectional single-centre survey of HCW over a 3-week period.

SETTING

tertiary public hospital.

PARTICIPANTS

HCW caring for deteriorating or aggressive patients.

MAIN OUTCOME MEASURES

the primary outcome was to assess HCW perspectives in attending Code-95 calls. Secondary outcomes were to identify any differences related to craft group, age, experience or presence of comorbidities.

RESULTS

A total of 297 responses was analysed; 86.7% of HCW (n = 257) attending Code-95 calls reported anxiety. Medical staff reported greater anxiety in comparison to nursing staff (93.8% vs 78.5%; P = 0.002). Efferent team reported higher anxiety in contrast to afferent team (92.6% vs 58.8%; P = 0.021). There was no significant difference in perceived anxiety based on age (≤40 vs >40 years of age), years of experience (≤5 vs >5 years), comorbidities or mental illness; 54% reported concerns about adequacy of infection-control policies and personal protective equipment; 45% were worried about inadequate training for responding to Code-95 calls.

CONCLUSIONS

Most surveyed HCW supported Code-95 announcements pre-warning them of potential COVID-19 exposure when attending a RRC. However, the majority of HCW reported anxiety when attending these calls. Medical and efferent team HCW perceived greater anxiety compared to nursing and afferent team HCW. The Code-95 system to pre-warn rapid response teams may be a useful addition to protecting HCW from infectious diseases, although broader implementation will require greater resourcing, training and support.

Reduction of in-hospital cardiac arrest rates in intensive care-equipped New South Wales hospitals in association with implementation of Between the Flags rapid response system

BACKGROUND

The NSW Clinical Excellence commission introduced the 'Between the Flags' programme, in response to the death of a young patient, as a system-wide approach for early detection and management of the deteriorating patient in all NSW hospitals. The impact of BTF implementation on the 35 larger hospitals with intensive care units (ICU) has not been reported previously.

AIM

To assess the impact of 'Between the Flags' (BTF), a two-tier rapid response system across 35 hospitals with an ICU in NSW, on the incidence of in-hospital cardiac arrests and the incidence and outcome of patients admitted to an ICU following cardiac arrest and rapid response team activation.

METHODS

This is a prospective observational study of the BTF registry (August 2010 to June 2016) and the Australian and New Zealand Intensive Care Society Adult Patient Database (January 2008 to December 2016) in 35 New South Wales public hospitals with an ICU. The primary outcome studied was the proportion of in-hospital cardiac arrests. Secondary outcomes included changes in the severity of illness and outcomes of cardiac arrest admissions to the ICU and changes in the volume of rapid response calls.

RESULTS

The cardiac arrest rate per 1000 hospital admissions declined from 0.91 in the implementation period to 0.70. Propensity score analysis showed significant declines in ICU and hospital mortality and length of stay for cardiac arrest patients admitted to the ICU (all P < 0.001).

CONCLUSIONS

The BTF programme was associated with a significant reduction in cardiac arrests in hospitals and ICU admissions secondary to cardiac arrests in 35 NSW hospitals with an ICU.

Protected code blue: using in situ simulation to develop a protected code blue and modify staff training protocol-experience in a large community teaching hospital during the COVID-19 pandemic

The surge in clinical demand, shortage in personal protective equipment and high-exposure risk for healthcare workers during the COVID-19 pandemic has challenged hospital common practices and forced a reassessment of care delivery models. Code blue teams are highly specialised units that partake in life-saving situations that can jeopardise the safety of team members. There is a paucity of guidance in regards to proper infection control measures to protect the responders.This study describes a methodical approach to assessing vulnerabilities to transmission of SARS-CoV-2 within existing code blue practices, modalities to limit the number of code blue team responders and modifications to the protocol at a large community teaching hospital. The effort undertaken faced challenges due to the nature of the pandemic and the increased demand on healthcare workers. Quality improvement methods facilitated our protocol design and implementation. To this date, there has been no identified COVID-19 disease in any protected code blue (PCB) team members. We recommend that similar practices be considered and adopted widely and practised periodically.

Evaluation of the blue code system established in the health campus of a university hospital

OBJECTIVE

We report the hospital outcomes after implementing the blue code system in our hospital and health campus. We also aimed to determine factors related to mortality.

METHODS

This is a retrospective observational study of the patients who received cardiopulmonary resuscitation (CPR). All blue code calls for all age groups between March 15, 2013, and April 30, 2015 were analyzed. Logistic regression analysis was performed to find independent predictors of in-hospital mortality.

RESULTS

A total of 155 patients from the blue code calls were evaluated. Return of spontaneous circulation was achieved in 45.5% of patients, and 54.8% of the patients had died at the end of the CPR. The hospital discharge rate was 20%. Of all patients, 65% were adults with a survival rate of 7.9%, whereas pediatric patients had a 44.2% survival rate. Asystole and pulseless electrical activity were the predominant electrocardiography rhythms in 92.4% of patients. The comparison of survivors and nonsurvivors revealed that nonsurvivors were older, had more cancer as the comorbidity, had a more cardiac arrest, and sepsis as the underlying cause and had >20 min of CPR. The logistic regression analysis demonstrated the independent risk factors for mortality as arrest at a hospital ward, and sepsis as the underlying cause and being adult patient.

CONCLUSION

The performance of the blue code system should be evaluated periodically. Every effort should be made to prevent unexpected cardiac arrests and increase hospital discharge with good neurologic outcomes.

ICU shift related effects on sleep, fatigue and alertness levels

BACKGROUND

Shift work may lead to suboptimal sleep resulting in impaired alertness, and lowered performance levels, all of which can lead to medical errors.

AIMS

To examine fatigue, sleepiness and behavioural alertness prospectively in a tertiary level Australian intensive care unit (ICU).

METHODS

All full-time doctors providing 24-h resident cover on a 12-h day and 12-h night shift roster were invited to participate in this study. Data collected included Epworth Sleepiness Scale (ESS), sleep and awake history, Samn-Perelli Fatigue (SPF) Scale, Karolinska Sleepiness Scale (KSS) and iOS-based Psychomotor Vigilance Test (behavioural alertness). Data about medical emergency team (MET) shifts were collected separately as they were perceived to be busier shifts.

RESULTS

Twenty-nine ICU doctors participated in this study for a consecutive 6-week period. At baseline the median (interquartile range (IQR)) ESS was 5 (3-9). Day shift leads to an increase in fatigue and sleepiness (both P < 0.01). Night shift leads to worsening in fatigue, sleepiness and psychomotor vigilance (all P < 0.01). MET shifts had a lower psychomotor vigilance than non-MET shifts. The difference in the psychomotor vigilance was mostly due to the difference in recorded lapses and response time.

CONCLUSIONS

Shift work ICU doctors experience high levels of fatigue and sleepiness. Night shifts also lead to decreased vigilance. This is even more evident in doctors working MET shifts. These factors may lead to errors. Optimal rostering may reduce these effects and improve patient safety.

Effectiveness of chest pain centre accreditation on the management of acute coronary syndrome: a retrospective study using a national database

BACKGROUND

Large-scale real-world data to evaluate the impact of chest pain centre (CPC) accreditation on acute coronary syndrome (ACS) emergency care in heavy-burden developing countries like China are rare.

METHODS

This study is a retrospective study based on data from the Hospital Quality Monitoring System (HQMS) database. This study included emergency patients admitted with ACS to hospitals that uploaded clinical data continuously to the database from 2013 to 2016. Propensity score matching was used to compare hospitals with and without CPC accreditation during this period. A longitudinal self-contrast comparison design with mixed-effects models was used to compare management of ACS before and after accreditation.

RESULTS

A total of 798 008 patients with ACS from 746 hospitals were included in the analysis. After matching admission date, hospital levels and types and adjusting for possible covariates, patients with ACS admitted to accredited CPCs had lower in-hospital mortality (OR=0.70, 95% CI 0.53 to 0.93), shorter length of stay (LOS; adjusted multiplicative effect=0.89, 95% CI 0.84 to 0.94) and more percutaneous coronary intervention (PCI) procedures (OR=3.53, 95% CI 2.20 to 5.66) than patients admitted in hospitals without applying for CPC accreditation. Furthermore, when compared with the 'before accreditation' group only in accredited CPCs, the in-hospital mortality and LOS decreased and the usage of PCI were increased in both 'accreditation' (for in-hospital mortality: OR=0.86, 95% CI 0.79 to 0.93; for LOS: 0.94, 95% CI 0.93 to 0.95; for PCI: OR=1.22, 95% CI 1.18 to 1.26) and 'after accreditation' groups (for in-hospital mortality: OR=0.90, 95% CI 0.84 to 0.97; for LOS: 0.89, 95% CI 0.89 to 0.90; for PCI: OR=1.36, 95% CI 1.33 to 1.39). The significant benefits of decreased in-hospital mortality, reduced LOS and increased PCI usage were also observed for patients with acute myocardial infarction.

CONCLUSIONS

CPC accreditation is associated with better management and in-hospital clinical outcomes of patients with ACS. CPC establishment and accreditation should be promoted and implemented in countries with high levels of ACS.

Variation in the design of Do Not Resuscitate orders and other code status options: a multi-institutional qualitative study

BACKGROUND

US hospitals typically provide a set of code status options that includes Full Code and Do Not Resuscitate (DNR) but often includes additional options. Although US hospitals differ in the design of code status options, this variation and its impacts have not been empirically studied.

DESIGN AND METHODS

Multi-institutional qualitative study at 7 US hospitals selected for variability in geographical location, type of institution and design of code status options. We triangulated across three data sources (policy documents, code status ordering menus and in-depth physician interviews) to characterise the code status options available at each hospital. Using inductive qualitative methods, we investigated design differences in hospital code status options and the perceived impacts of these differences.

RESULTS

The code status options at each hospital varied widely with regard to the number of code status options, the names and definitions of code status options, and the formatting and capabilities of code status ordering menus. DNR orders were named and defined differently at each hospital studied. We identified five key design characteristics that impact the function of a code status order. Each hospital's code status options were unique with respect to these characteristics, indicating that code status plays differing roles in each hospital. Physician participants perceived that the design of code status options shapes communication and decision-making practices about resuscitation and life-sustaining treatments, especially at the end of life. We identified four potential mechanisms through which this may occur: framing conversations, prompting decisions, shaping inferences and creating categories.

CONCLUSIONS

There are substantive differences in the design of hospital code status options that may contribute to known variability in end-of-life care and treatment intensity among US hospitals. Our framework can be used to design hospital code status options or evaluate their function.

Clinical Outcomes of patients triggering Medical Emergency Team calls for sinus tachycardia

BACKGROUND

Medical emergency team (MET) calls allow unstable patients to be identified earlier and enables clinicians to institute timely management to ameliorate physiological stress. Sinus tachycardia is a common cause for triggering MET calls. In this study, outcome measures relating to patients who have a MET call for sinus tachycardia were analysed.

METHODS

Two hundred and ninety-three consecutive patients who had MET calls as a result of sinus tachycardia were included in the study. Outcome measures assessed included inpatient mortality, duration of hospital stay, change in disposition of patient care, change in goals of care, and underlying aetiology. Comparison between medical and procedural patients was also performed.

RESULTS

There were 154 patients in the medical group compared to 139 patients in the procedural group. Inpatient mortality was 13% and 6% respectively (p-value= 0.065). The duration of hospital stay was longer in the medical group (11 vs. 8 days, p-value= 0.295). Sepsis accounted for about 50% of MET call diagnoses in both groups. Around 20% of patients in both groups did not have a clear cause identified for the sinus tachycardia. About one-fifth of the patients in both groups were transferred to intensive care following the MET call (17% vs. 16%; p-value= 0.823).

CONCLUSIONS

Sinus tachycardia triggering MET call is not a benign condition. It not infrequently requires escalation of care and is associated with significant inpatient mortality. Clinicians should have a high index of suspicion for sepsis as the underlying cause. This article is protected by copyright. All rights reserved.

Characteristics and outcomes of rapid response team activations for hypotension in orthopaedic patients

BACKGROUND

Hypotension following orthopaedic surgery has been associated with increased morbidity and mortality. Rapid response teams (RRT) review patients on hospital wards with hypotension.

AIM

To evaluate the epidemiology of hypotensive RRT activations in adult orthopaedic patients to identify contributing factors and areas for future quality improvement.

METHODS

Timing of RRT activations, presumed causes of hypotension and associated treatments were assessed.

RESULTS

Among 963 RRT activations in 605 patients over 3 years, the first calls of 226 of 605 patients were due to hypotension, and 213 (94.2%) of 226 had sufficient data for analysis. The median age was 79 (interquartile range 66-87) years; 58 (27.2%) were male, and comorbidities were common. Most (68%) surgery was emergent, and 75.1% received intraoperative vasopressors for hypotension. Most activations occurred within 24 h of surgery, and hypovolaemia, infection and arrhythmias were common presumed causes. Fluid boluses occurred in 173 (81.2%), and the time between surgery and RRT activation was 10 (4.0-26.5) h. in cases where fluid boluses were given, compared with 33 (15.5-61.5) h. where they were not (P < 0.001). Blood transfusion (30, 14.1%) and withholding of medications were also common. Hospital mortality was 8.5% (18), and 13.6% (29) were admitted to critical care at some stage. In-hospital death was associated with older age, functional dependence, arrhythmia and presumed infection.

CONCLUSIONS

Hypotension-related RRT calls in orthopaedic patients are common. Future interventional studies might focus on perioperative fluid therapy and vaso-active medications, as well as withholding of anti-hypertensive medications preoperatively.

Leadership in intensive care: A review

An integrative review of the literature specific to leadership within the intensive care unit was planned to guide future research. Four databases were searched. Study selection was based on predetermined inclusion and exclusion criteria and a quality check was done. Data extraction and synthesis involved developing a preliminary thematic coding framework based on a sample of papers. The coding framework and all selected papers were entered into NVivo software. All papers were then coded to the previously identified themes. Themes were summarised and presented with illustrative quotes highlighting key findings. In total, 1102 relevant quotations were coded across the 28 included papers. Four themes pertaining to leadership were described and analysed: (a) leadership dimensions and discourses; (b) leadership experiences; (c) facilitators and/or barriers to leadership; and (d) leadership outcomes. The literature was found to focus on leader behaviours, as well as the leader dimensions of role allocation, clinical and communication skills and traditional hierarchies. Positive behaviours mentioned included good decision-making, staying calm under pressure and being approachable. Leadership experiences (and outcomes) are typically reported to be positive. Personal individual factors seem the biggest enablers and barriers to leadership within the intensive care unit. Training is considered to be a facilitator of leadership within the intensive care unit. This study highlights the current literature on leadership in intensive care medicine and provides a basis for future research on interventions to improve leadership in the intensive care unit.

Critical care transition programs on readmission or death: A systematic review and meta-analysis

BACKGROUND

Deterioration after ICU discharge may lead to readmission or even death. Interventions (eg, critical care transition programs) have been developed to improve the clinical handover between the ICU and the ward. We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) according to Cochrane Handbook and Grading of recommendations, assessment, development and evaluations (GRADE) methodology to assess the impact of these interventions on readmission and death (PROSPERO, no CRD42019121746).

METHODS

We searched PubMed/MEDLINE, CINAHL, AMED, PsycINFO, and the Cochrane Central Register for Controlled Trials from inception until January 2019. We included historically controlled studies that evaluated critical care transition programs in adults discharged from the ICU. Readmission and in-hospital mortality were the primary outcomes. Risk of bias, publications bias, and the quality of evidence were assessed with the ROBINS-Itool, funnel plot and GRADE, respectively.

RESULTS

Fifteen observational studies were included (11 in meta-analysis). All studies had at least serious risk of bias. ICU discharge within a critical care transition program modestly reduced the risk of readmission (RR 0.78; 95% CI: 0.64-0.96; TSA-adjusted 95% CI: 0.59-1.03) but not in-hospital mortality (RR 0.82; 95% CI: 0.64-1.06; TSA-adjusted 95% CI: 0.49-1.37). There was substantial heterogeneity among studies. TSA indicated lack of firm evidence. The GRADE quality of evidence on outcomes was very low.

CONCLUSIONS

We found no clear benefit in terms of reducing risk of readmission or death after ICU discharge, however, with overall very low certainty of evidence.

Evaluation of calling criteria for the rapid response system utilising single versus multiple physiological parameter disturbances

BACKGROUND

The Adult Deterioration Detection System for Medical Emergency Team (MET) activation is widely used and includes single parameter (SP-MET) and multiple parameter (MP-MET) disturbances. Whether the patient characteristics, interventions and outcomes differ for SP-MET compared with MP-MET is uncertain.

AIMS

To describe MET interventions and outcomes of SP versus MP MET in the Acute Medical Unit (AMU) of a tertiary care hospital.

METHODS

Retrospective audit over 6 months comparing SP-MET and MP-MET groups.

RESULTS

SP-MET constituted 64.1% (168) of 262 AMU MET calls, most commonly for hypotension (35.5%) and tachycardia (14.1%). There were no significant differences in demographic and disease characteristics between the two groups. Common interventions included fluid/electrolyte replacement in 139 (52%), oxygen therapy in 46 (17%) and non-invasive ventilation in 33 (13%) patients. After MET intervention, 82.4% patients stayed on the ward, 8.4% died/were palliated, 6.5% were transferred to the Intensive Care Unit (ICU) and 2.7% patients required urgent transfer to the theatre for intervention. SP-MET patients were more likely to remain on the ward (88.7% vs 71.3%; P = 0.001), receive ward-based interventions (85.1% vs 61.7%; P < 0.001) and less likely to experience death/palliation (4.2% vs 16%, P = 0.001) compared with the MP-MET group. MP-MET were independently associated with negative outcomes (OR 3.10; 95% CI 1.60-6.00).

CONCLUSION

SP-MET identify a cohort of patients at lower risk of requiring escalation of care and ICU admission. Given the resource intensity of MET activation, further research is warranted to determine whether alternative response strategies are appropriate for selected SP disturbances.

Predictors of acute hospital mortality and length of stay in patients with new-onset atrial fibrillation: a first-hand experience from a medical emergency team response provider

BACKGROUND

Atrial fibrillation (AF) occurs frequently following cardiothoracic surgery and treatment decisions are informed by evidence-based clinical guidelines. Outside this setting there are few data to guide clinical management.

AIM

To describe the characteristics, management and outcomes of hospitalised adult patients with new-onset AF.

METHODS

The medical emergency team (MET) database was utilised to identify patients who had a 'MET call' activated for tachycardia between 2015 and 2016. Patients with sinus tachycardia, pre-existing AF/atrial flutter or other known tachyarrhythmia were excluded. Primary outcomes were length of hospital stay and in-hospital mortality.

RESULTS

New-onset AF was identified in 137 patients: 68 medically managed; 38 non-cardiothoracic post-operative; and 31 cardiothoracic post-operative. Mean age was 74 ± 11.6 years and 72 (53%) were male. Of 79 patients who underwent echocardiography, 80% had left atrial dilatation and 14% had reduced left ventricular ejection fraction (LVEF). Mean length of stay (LOS) was 12 days and in-hospital mortality rate was 11%. On multivariable analysis, the odds of death during acute hospitalisation was 7.4 times higher in patients with heart failure with reduced LVEF (odds ratio 7.4, 95% confidence interval (CI) 1.23-44.8, P = 0.028). Length of acute hospital stay increased by 36% if the duration of AF was longer than 48 h (beta coefficient 0.36, 95% CI -0.015 to 0.74, P = 0.059).

CONCLUSION

Left ventricular systolic dysfunction in hospitalised patients with new-onset AF is associated with increased all-cause mortality whereas lower serum potassium levels are associated with an increased LOS. A prospective study is planned to compare outcomes based on in-hospital treatment strategies.

A rapid response team is associated with reduced overall hospital mortality in a Chinese tertiary hospital: a 9-year cohort study

Background

Although the evidence for its effectiveness remains uncertainty, rapid response systems are implemented across many hospitals across the world. Increasingly, hospitals in China have recently started to adopt a medical emergency or rapid response team (RRT). Hence, we aimed to determine whether the implementation of an RRT in Chinese hospitals also improved outcomes.

Methods

Our hospital is a Joint Commission International (JCI) accredited, tertiary teaching hospital with 1,200 beds. We conducted a retrospective cohort study comparing 60 months after the implementation of the RRT (January 1, 2013, to December 31, 2017) and 36 months before implementation (January 1, 2009, to December 31, 2011). The outcomes included the overall hospital mortality and incidence of codes.

Results

We analyzed 144,673 non-obstetric hospital admissions and 1,269,621 patient days in the control period and 348,687 non-obstetric hospital admissions and 2,361,913 patient days after the RRT implementation. The RRT was activated 834 times (2.39 calls per 1,000 patients and 0.35 call per 1,000 patient-days). There was no difference in the code rate (0.23 vs. 0.17 per 1,000 patient days, P=0.379) between the two periods. Although the hospital mortality had remained stable around 3.0 per 1,000 patients from 2009 to 2011, there was a significant 40% decrease of overall hospital mortality from 2.95 to 1.77 per 1,000 non-obstetric patients after the implementation of RRT (P=0.001), and the annual mortality showed a consistent decrease (P=0.037 for the trend). Moreover, the increase of RRT activations was significantly correlated with the decrease of hospital mortality (P=0.025).

Conclusions

RRT implementation was associated with reduced overall hospital mortality in a Chinese tertiary hospital.

How to facilitate a rapid response system in Japan: a promotion course based on TeamSTEPPS

Aim

In Japan, the number of facilities introducing a rapid response system (RRS) has been increasing. However, many institutions have had unsuccessful implementations. In order to implement RRS smoothly, a plan that meets the needs of each hospital is needed.

Methods

Rapid response system teams from each hospital, including a physician and staff in charge of medical safety, from the RRS online registry were invited to attend a workshop. The workshop aimed to develop and implement RRS. The course curriculum was based on the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) developed in the USA. Participating facilities were required to formulate an RRS introduction plan referring to Kotter’s 8‐step change model to overcome barriers in the implementation of RRS. The change in medical emergency team activations comparing the intervention and control group hospitals was compared.

Results

Sixteen institutions were eligible for this study. After participating in the workshop, there was a tendency toward more frequent activation of medical emergency teams in the intervention group (P = 0.075). According to a self‐evaluation from each facility, there is great difficulty in overcoming the 5th step of Kotter’s model (empower people to act the vision).

Conclusion

This step‐by‐step evaluation clearly identified a problem with implementation and provided measures for resolution corresponding to each facility. There was a major barrier to overcome the 5th step of Kotter’s model in leading change, which represents the attitude toward implementing RRS in institutions.

First report based on the online registry of a Japanese multicenter rapid response system: a descriptive study of 35 institutions in Japan

AIM

Although the concept of a rapid response system (RRS) has been gradually accepted in Japan, detailed information on the Japanese RRS is not well known. We provide the first report of the RRS epidemiological situation based on 4 years of RRS online registry data.

METHODS

This is a prospective observational study. All patients registered between January 2014 and March 2018 were eligible for this study. Data related to RRS including physiological measurements were recorded. The mortality rates after rapid response team/medical emergency team (RRT/MET) intervention and after 30 days were recorded as outcomes.

RESULTS

In total, 6,784 cases were registered at 35 facilities. Cancer (23.1%) was the most common existing comorbidity. Limitation of medical treatment was identified in 12.7% of the cases. The respiratory category was most frequently activated in 41.3% of the cases. Only two institutions had received more than 15 calls per 1,000 admissions. During RRT/MET intervention, death occurred in 3.6% and transfers to intensive care units occurred in 28.2% of the cases. After 30 days, the mortality rate was significantly higher in the night than in the day shift (30.7% versus 20.4%, respectively, P < 0.01).

CONCLUSIONS

We report the first epidemiological study of RRS in Japan. Japanese facilities had a very low rate of RRT/MET calls and a higher mortality rate in the night than in the day shift. Further promotion to increase the number of calls and implementation of a 24-h RRT/MET is required.

The effectiveness of a national early warning score as a triage tool for activating a rapid response system in an outpatient setting: A retrospective cohort study

Rapid response system (RRS) efficacy and national early warning score (NEWS) performances have largely been reported in inpatient settings, with few such reports undertaken in outpatient settings.This study aimed to investigate NEWS validity in predicting poor clinical outcomes among outpatients who had activated the RRS using single-parameter criteria.A single-center retrospective cohort studyFrom April 1, 2014 to November 30, 2017 in an urban 350-bed referral hospital in JapanWe collected patient characteristics such as activation triggers, interventions, arrival times, dispositions, final diagnoses, and patient outcomes. Poor clinical outcomes were defined as unplanned intensive care unit transfers or deaths within 24 hours. Correlations between the NEWS and clinical outcomes at the time of deterioration and disposition were analyzed.Among 31 outpatients, the NEWS value decreased significantly after a medical emergency team intervention (median, 8 vs 4, P < .001). The difference in the NEWS at the time of deterioration and at disposition was significantly less in patients with poor clinical outcomes (median 3 vs 1.5, P = .03). The area under the curve (AUC) for the NEWS high-risk patient group at the time of deterioration for predicting hospital admission was 0.85 (95% confidence interval [CI], 0.67-1.0), while the AUC for the NEWS high-risk patient group at disposition for predicting poor clinical outcomes was 0.83 (95% CI, 0.62-1.0).The difference between the NEWS at the time of deterioration and at disposition might usefully predict admissions and poor clinical outcomes in RRS outpatient settings.

Rapid response team trigger modifications: are we using them safely?

BACKGROUND

Rapid response teams (RRT) were first proposed as a means of reducing inpatient morbidity and mortality. Modifying RRT activation triggers poses a potential risk for delayed recognition of a deteriorating patient. Trigger modifications have not been validated for safety.

AIMS

To determine if RRT trigger modifications are associated with: increased frequency of recurrent RRT activation; increased length of stay (LOS); increased intensive care admission; and increased in-hospital mortality.

METHODS

A retrospective audit of all RRT activations occurring at the Launceston General Hospital (LGH) over an 18-month period was performed.

RESULTS

Rate of recurrent RRT activations did not decrease with the use of trigger modifications around the time of RRT activation, and for patients with two modifications, the frequency increased (1.98 vs 1.32, P = 0.007). LGH LOS increased for patients with any trigger modifications compared to those with none (11 vs 9, P = 0.0002), and for patients with two modifications (11.5 vs 9, P = 0.010). Total hospital LOS increased for patients with any modifications compared to patients with none (12 vs 10, P = 0.002). There was no significant association between trigger modifications and frequency of intensive care unit admission. The relative risk of in-hospital death increased with increasing numbers of trigger modifications (relative risk 1.38-4.89).

CONCLUSIONS

Trigger modifications are associated with increased hospital LOS and increased rate of in-hospital death and do not reduce the number of recurrent events. For patients in whom escalation of care is not appropriate, the presence of multiple trigger modifications at the time of an RRT activation may be a useful trigger for conversations around goals of care.

Goals of care conversations and documentation in patients triggering medical emergency team calls

BACKGROUND

It is widely accepted that early discussions about goals of care (GOC) should occur during a hospital admission. Whilst rapid response systems such as Medical Emergency Team (MET) calls were designed to identify patients at risk of deterioration early enough in their illness to intervene, it is becoming apparent that these teams frequently diagnose the dying patient.

AIMS

To determine how frequently Launceston General Hospital MET doctors are involved in discussions surrounding GOC.

METHODS

A retrospective audit of all MET calls and Code Blues at the Launceston General Hospital over an 18 month period was performed.

RESULTS

50% of MET calls occurred in patients with no valid GOC form completed prior. At 3% of events, the GOC form was completed for the first time, and at 3% it was modified. At a further 3% the notes implied there had been a modification to the GOC but the form had not been completed.

CONCLUSIONS

This audit confirms that documentation surrounding GOC is inadequate, and that at 9% of MET calls, MET doctors are involved in discussions surrounding treatment limitations. This suggests that further education and training is required for doctors working in inpatient care, including those who staff the MET.

High Rate of Medical Emergency Team Activation in Children with Tracheostomy

Pediatric in-patients with tracheostomy (PIT) are at high risk for clinical deterioration. Medical emergency teams (MET) have been developed to identify high-risk patients. This study compared MET activation rates between PITs and the general ward population. This was a retrospective cohort study conducted at a tertiary pediatric hospital. The primary outcome (MET activation) was obtained from a database. Between 2008 and 2014, the MET activation rate was significantly higher in the PIT group than the general ward population (14 vs. 2.9 per 100 admissions, p  < 0.001). PITs are at significantly higher risk for MET activation. Strategies should be developed to reduce their risk on the wards.

Improving rapid response system performance in a Chinese Joint Commission International Hospital

Objective

To assess the impact of a regional rapid response system (RRS) implemented in a Chinese Joint Commission International Hospital on the timely treatment of patients with serious adverse events (SAEs).

Methods

Clinical SAEs, activation periods, reasons for RSS activation, and patient outcomes were assessed using SAE response sheets at admission to the hospital and over 31 months of follow-up.

Results

We found that 192 events were called by medical staff and 6 were called by auxiliary staff. Reasons for the 385 RRS activations included: unconsciousness (133; 34.5%), and airway obstruction and absent carotid pulse (49 each; 12.7%). The average arrival time of the medical emergency team was 2.4 ± 0.1 minutes. There were 123 (62.1%) RRS activations during daytime working hours (8:00–17:00); CPR was performed in 86 (43.4%) cases. Outcomes of RRS were: vital signs stabilized in 82 (41.4%) patients and 61 (30.8%) patients were transferred to ICU.

Conclusion

Our experience showed that the regional RRS has led to better integrated multidisciplinary cooperation and reduced time for treating patients with SAEs, resulting in success of the RRS.

Pharmacist involvement on a rapid response team

PURPOSE

The effect of a pharmacist on a rapid response team (RRT) was investigated.

METHODS

This study evaluated 234 patients before and 157 patients after pharmacist involvement on an RRT. The primary outcome was time to medication administration, with a goal turnaround time of less than 30 minutes. Secondary outcomes included most frequently used medications, readmissions to the intensive care unit (ICU) within 48 hours, number of rapid responses that resulted in ICU admission, length of hospital stay, and survival to hospital discharge. Additionally, pharmacist interventions were tracked in the postinterventional group.

RESULTS

The preinterventional group screened 326 rapid response events, of which 234 were included for analysis; during the postinterventional phase, 256 rapid response events were evaluated, of which 157 were included. The primary outcome, median time to medication administration from central pharmacy, was lower in the postinterventional group compared with the preinterventional group (32.0 minutes versus 64.5 minutes, p = 0.004). ICU admission rates following rapid response were not significantly different between the two groups. Additionally, there were no significant differences between rates of medical emergency and survival to hospital discharge. The most common medications administered were metoprolol and naloxone. Pharmacists provided documentation for 90 of 157 (57%) patient cases. In the 90 cases with documentation, 18 (20% of patients) had documented pharmacist interventions, including dosing assistance for 8 cases (44% of interventions).

CONCLUSION

The addition of a pharmacist to an RRT reduced time to medication administration, helped improve medication accessibility, and helped optimize medication selection and dosing.

Improving referral to psychological support unit at Saudi Red Crescent Authority in Riyadh Region

The Psychological Support Unit (PSU) performance in Saudi Red Crescent Authority (SRCA) showed that only a small number of case referred seeking psychological advice and management from PSU among all SRCA employees. However, research shows that between 28% and 52% of emergency medical services (EMS) providers usually seek psychological help in various EMS cultures, where 86% of them usually suffer from critical stress. Thus, we decided to design a quality improvement project that aims to improve the referral process by increasing cases referred to the PSU at SRCA in Riyadh Region by 75% in 2 months. A multidisciplinary team has been formed to analyse the problem using quality tools including, brainstorming, fishbone diagram and flow chart of the PSU processes. Several possible reasons have been identified, such as lack of awareness among the SRCA’s employees about PSU and its services, and the concern about privacy and confidentiality during psychological consultations in the PSU, in addition to the long referring process to PSU. The team decided to test the following change ideas: increasing the awareness of employees about the PSU services, improving the privacy and confidentiality during the consultation using electronic channels, and finally re-engineering the referral process to make it lean and remove all the unnecessary steps. Several improvement interventions have been tested sequentially in three consecutive Plan-Do-Study-Act cycles on a weekly basis. The project findings demonstrated that the first change idea was successful but not reaching the target while the second change had led to huge impact exceeding our target but with short effect. On the other hand, although the third change idea of re-engineering the PSU referral process had led to negative result initially, over the following weeks of measurement the results turned to be positive and meeting our expectations. We concluded that re-engineering referral process is most effective improvement intervention among other change ideas in term of magnitude and sustainability of the effect on increasing the number of referral cases to the PSU. We recommend conducting further testing and measuring of these change ideas in other PSU across the SRCA to understand the diffident context in other regions of SRCA.

Local emergency medical response after a terrorist attack in Norway: a qualitative study

INTRODUCTION

On 22 July 2011, Norway suffered a devastating terrorist attack targeting a political youth camp on a remote island. Within a few hours, 35 injured terrorist victims were admitted to the local Ringerike community hospital. All victims survived. The local emergency medical service (EMS), despite limited resources, was evaluated by three external bodies as successful in handling this crisis. This study investigates the determinants for the success of that EMS as a model for quality improvement in healthcare.

METHODS

We performed focus group interviews using the critical incident technique with 30 healthcare professionals involved in the care of the attack victims to establish determinants of the EMS' success. Two independent teams of professional experts classified and validated the identified determinants.

RESULTS

Our findings suggest a combination of four elements essential for the success of the EMS: (1) major emergency preparedness and competence based on continuous planning, training and learning; (2) crisis management based on knowledge, trust and data collection; (3) empowerment through multiprofessional networks; and (4) the ability to improvise based on acquired structure and competence. The informants reported the successful response was specifically based on multiprofessional trauma education, team training, and prehospital and in-hospital networking including mental healthcare. The powerful combination of preparedness, competence and crisis management built on empowerment enabled the healthcare workers to trust themselves and each other to make professional decisions and creative improvisations in an unpredictable situation.

CONCLUSION

The determinants for success derived from this qualitative study (preparedness, management, networking, ability to improvise) may be universally applicable to understanding the conditions for resilient and safe healthcare services, and of general interest for quality improvement in healthcare.

Rapid response team calls to obstetric patients in a busy quaternary maternity hospital

AIMS

There is limited published information regarding intensive care unit (ICU) led rapid response team (RRT) calls to obstetric patients. We examined the characteristics of RRT calls to obstetric patients at a tertiary teaching hospital.

METHODS

Details of calls to pregnant and postpartum patients between October 2010 and June 2014 were obtained from the hospital RRT database. Each was retrospectively examined for data on patient demographics, call trigger, interventions and outcomes. Local obstetric-specific escalation practices (Code Pink/Green) for obstetrical concerns (not mandating maternal instability/involvement of the ICU team), were excluded.

RESULTS

There were 106 RRT calls logged during 43 months, and 97 had data available for analysis. Women currently pregnant accounted for 33% of calls and postpartum women 67%, with nearly half of these occurring more than 24 h post-delivery. The most common reason (29% of calls) for calling the RRT was hypotension, followed by 'concern about patient' (21%) and decreased Glasgow Coma Score (GCS) (17%). An escalation in the environment of care occurred after 32% of calls, with approximately 11% of calls necessitating direct ICU admission. Twenty-three percent of all calls were to women who had an ICU admission during their hospital stay. Among the cohort who received an RRT call, there was one maternal and three neonatal deaths.

CONCLUSION

At our institution generic RRT calls are called to both pregnant and postpartum women, and frequently result in an escalation in the care environment. Further study is required to understand better the specific needs of this important population.

Epidemiology and Clinical Characteristics of Rapid Response Team Activations

Background

To ensure patient safety and improvements in the quality of hospital care, rapid response teams (RRTs) have been implemented in many countries, including Korea. The goal of an RRT is early identification and response to clinical deterioration in patients. However, there are differences in RRT systems among hospitals and limited data are available.

Methods

In Seoul St. Mary's Hospital, the St. Mary's Advanced Life Support Team was implemented in June 2013. We retrospectively reviewed the RRT activation records of 287 cases from June 2013 to December 2016.

Results

The median response time and median modified early warning score were 8.6 minutes (interquartile range, 5.6 to 11.6 minutes) and 5.0 points (interquartile range, 4.0 to 7.0 points), respectively. Residents (35.8%) and nurses (59.1%) were the main activators of the RRT. Interestingly, postoperative patients account for a large percentage of the RRT activation cases (69.3%). The survival rate was 83.6% and survival was mainly associated with malignancy, Acute Physiology and Chronic Health Evaluation-II score, and the time from admission to RRT activation. RRT activation with screening showed a better outcome compared to activation via a phone call in terms of the intensive care unit admission rate and length of hospital stay after RRT activation.

Conclusions

Malignancy was the most important factor related to survival. In addition, RRT activation with patient screening showed a better outcome compared to activation via a phone call. Further studies are needed to determine the effective screening criteria and improve the quality of the RRT system.

Sustaining Health Care Interventions to Achieve Quality Care: What We Can Learn From Rapid Response Teams

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.

Epidemiology of in-hospital mortality in acute patients admitted to a tertiary-level hospital

BACKGROUND

Healthcare professionals may have difficulty in recognising the dying patient in acute care settings, and yet, this is essential if timely end-of-life care is to be provided. While approximately one-third of patients who pass away in-hospital are reviewed by the rapid response team (RRT), there is limited available research on other factors associated with mortality within the hospital setting.

AIMS

To describe the epidemiology of in-hospital mortality within a tertiary-level hospital, particularly in the context of RRT activation.

METHODS

We utilised the database extraction of demographic, admission and RRT activation data on acute patients discharged from an Australian acute tertiary hospital between 1 January 2009 and 31 December 2013. Analyses included simple descriptors, Chi-squared and non-parametric Kruskal-Wallis tests as appropriate.

RESULTS

Of the 44,297 patients discharged from our hospital, 1603 died during admission. The general medical, haematology/oncology and intensive care teams provided care for the majority of the patients who died. A small number of diagnoses had in-patient mortality rates of greater than 25%. These included respiratory failure, alcoholic liver disease, vascular disorders of the intestine, sepsis and aspiration pneumonia. Over 75% of patients who received a RRT call survived to hospital discharge; however, patients who received four or more RRT calls during admission had an in-hospital mortality rate of over 40%.

CONCLUSION

Acute in-patient mortality is unequally distributed throughout the hospital, and a small number of diagnoses has large associated in-patient mortality rates. Repeated involvement of the RRT is associated with in-patient mortality.