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Abstract
BackgroundFailure to recognise and respond to patient deterioration on hospital wards is a common cause of healthcare-related harm. If patients are not rescued and suffer a cardiac arrest as a result then only around 15% will survive. Track and Trigger systems have been introduced into the NHS to improve both identification and response to such patients. This study examines the association between the type of Track & Trigger System (TTS) (National Early Warning Score (NEWS) versus non-NEWS) and the mode of TTS (paper TTS versus electronic TTS) and incidence of in-hospital ward-based cardiac arrests (IHCA) attended by a resuscitation team.MethodsTTS type and mode was retrospectively collected at hospital level from 106 NHS acute hospitals in England between 2009 to 2015 via an organisational survey. Poisson regression and logistic regression models, adjusted for case-mix, temporal trends and seasonality were used to determine the association between TTS and hospital-level ward-based IHCA and survival rates.ResultsThe NEWS was introduced in England in 2012 and by 2015, three-fifths of hospitals had adopted it. One fifth of hospitals had instituted an electronic TTS by 2015. Between 2009 and 2015 the incidence of IHCA fell. Introduction or use of NEWS in a hospital was associated with a reduction of 9.4% in the rate of ward-based IHCA compared to non-NEWS systems (incidence rate ratio 0.906, p < 0.001). The use of an electronic TTS was also associated with a reduction of 9.8% in the rate of IHCA compared with paper-based TTS (incidence rate ratio 0.902, p = 0.009). There was no change in hospital survival.ConclusionsThe introduction of standardised TTS and electronic TTS have the potential to reduce ward-based IHCA. This is likely to be via a range of mechanisms from early intervention to institution of treatment limits. The lack of association with survival may reflect the complexity of response to triggering of the afferent arm of the rapid response system.
Highlights
Failure to recognise and respond to patient deterioration on hospital wards is a common cause of healthcare-related harm
Our observation that National Early Warning Score (NEWS) and electronic Track & Trigger System (TTS) are associated with fewer ward-based in-hospital ward-based cardiac arrests (IHCA) may be due to ward staff making earlier interventions [21], improved timeliness of referrals to staff with critical care skills [14, 22], or through initiation of treatment limitation decisions (e.g. use of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions)
Standardisation of TTS and the introduction of systems that both facilitate correct score calculation and automate the triggering of a response may lead to a reduction in ward-based IHCA through a range of mechanisms
Summary
Failure to recognise and respond to patient deterioration on hospital wards is a common cause of healthcare-related harm. This study examines the association between the type of Track & Trigger System (TTS) (National Early Warning Score (NEWS) versus non-NEWS) and the mode of TTS (paper TTS versus electronic TTS) and incidence of in-hospital ward-based cardiac arrests (IHCA) attended by a resuscitation team. Survival to discharge is around 13–20% [2, 3] These IHCA often reflect a failure to manage antecedent events – case reviews have shown that many patients exhibited signs of deterioration (physiological changes or level of consciousness) for up to 8 h beforehand [4, 5]. Track and Trigger systems were expected to reduce the incidence of IHCA by identifying deterioration at an earlier stage when there is greater opportunity to intervene and provide timely and appropriate care, be that increased monitoring, clinical review or the revision of decisions around limits of treatment. It is perhaps not surprising that an inconsistent picture of the impact of TTS on IHCA has emerged from studies over the last two decades [6,7,8]
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