Escalation Of Care Research Articles

Inpatient albuterol spacing as an indicator of discharge readiness

Introduction In children admitted for asthma exacerbation, multiple evidence-based, clinical practice guidelines exist to identify readiness for discharge. At many institutions, weaning of albuterol is part of the discharge process, though presently there is limited evidence to guide best practice. We sought to determine how many children required escalation of care once placed on every 4-h dosing of albuterol. Methods We performed a consecutive case series of pediatric patients between 5 and 18 years of age admitted to a single tertiary care center’s pediatric hospitalist service between April 2015 and April 2018 with a discharge diagnosis of asthma. Patients admitted to the intensive care unit (PICU) or a subspecialty service were excluded, as has been done previously. Time between albuterol administrations was tracked. “Treatment escalation” was defined as when a patient required more frequent albuterol more dosing after previously tolerating albuterol doses separated by more than 3.5 h. Results A total of 331 patients met inclusion criteria; 136 were female (41.1%), and the average age was 8.8 years. Twenty-six of the 331 patients (7.8%) required escalation of albuterol therapy. Eleven patients returned to the emergency department (ED) following discharge, 2 of which had experienced treatment escalation while admitted. Conclusions Our case series showed that most patients were safe to discharge after spacing albuterol treatments to 4 h, with few returns to the ED and readmissions. Albuterol spacing to every 4 h once appears to be a reasonable discharge criterion, but future studies are needed to determine if this is a safe and efficient.

Efficacy of remdesivir for hospitalized COVID-19 patients with end stage renal disease.

BACKGROUNDSince the beginning of corona virus disease 2019 (COVID-19) pandemic, there has been a widespread use of remdesivir in adults and children. There is little known information about its outcomes in patients with end stage renal disease who are on dialysis. AIMTo assess the clinical outcomes with use of remdesivir in adult patients with end stage kidney failure on hemodialysis. METHODSA retrospective, multicenter study was conducted on patients with end stage renal disease on hemodialysis that were discharged after treatment for COVID-19 between April 1, 2020 and December 31, 2020. Primary endpoints were oxygen requirements, time to mortality and escalation of care needing mechanical ventilation. RESULTSA total of 45 patients were included in the study. Twenty patients received remdesivir, and 25 patients did not receive remdesivir. Most patients were caucasian, females with diabetes mellitus and hypertension being the commonest comorbidities. There was a trend towards reduced oxygen requirement (beta = -25.93, X2 (1) = 6.65, P = 0.0099, probability of requiring mechanical ventilation (beta = -28.52, X2 (1) = 22.98, P < 0.0001) and mortality (beta = -5.03, X2 (1) = 7.41, P = 0.0065) in patients that received remdesivir compared to the control group.CONCLUSIONLarger studies are justified to study the effects of remdesivir in this high-risk population with end stage kidney disease on dialysis.

A Retrospective Characterization of Dexmedetomidine-Suspected Fever and Its Consequences in Adult Critically Ill Patients.

Current evidence for dexmedetomidine-suspected fever (DSF) is limited. Lack of recognition may lead to costly or potentially harmful interventions for critically ill patients. The primary objective was to characterize escalations of care related to DSF. Secondary objectives were to describe the incidence, severity, and consequences associated with DSF. A retrospective review was conducted in critically ill adults who developed fever ≥39°C within 12 h from initiation of dexmedetomidine, with resolution of fever to <39°C within 12 h after discontinuation. The primary outcome was percentage of patients who received an escalation of care due to fever. Secondary outcomes included the percentage of patients who developed a multidrug-resistant organism or Clostridium difficile infection. Eighteen of 3943 patients screened in 4099 encounters met criteria for DSF (0.4%). The majority were white (83.3%), male (66.7%), and underwent cardiac surgery (61.1%). Median (interquartile range [IQR]) time to fever onset and resolution were 5.5 (3.6-7.6) and 1.3 (1.0-2.9) h. Nine patients (50%) underwent infectious workup including antimicrobial initiation (n = 1, 5.6%), broadening of antimicrobials (n = 4, 22.2%), or culture collection (n = 9, 50%). Eleven patients (61.1%) underwent attempted temperature reduction. Twelve patients (66.7%) underwent diagnostic imaging. Incidence of multidrug-resistant organism and C. difficile infection were low (11.1 and 16.7% of fever patients, respectively). Incidence of DSF was low and more common in cardiac surgery patients. Unrecognized DSF led to an escalation of care in most patients. Dexmedetomidine exposure should be considered as a potential cause of fever in critically ill adults.

Efficiency of primary spine care as compared to conventional primary care: a retrospective observational study at an Academic Medical Center

BackgroundPrimary Spine Care (PSC) is an innovative model for the primary management of patients with spine-related disorders (SRDs), with a focus on the use of non-pharmacological therapies which now constitute the recommended first-line approach to back pain. PSC clinicians serve as the initial or early point of contact for spine patients and utilize evidence-based spine care pathways to improve outcomes and reduce escalation of care (EoC; e.g., spinal injections, diagnostic imaging, hospitalizations, referrals to a specialist). The present study examined 6-month outcomes to evaluate the efficiency of care for patients who received PSC as compared to conventional primary care. We hypothesized that patients seen by a PSC clinician would have lower rates of EoC compared to patients who received usual care by a primary care (PC) clinician.MethodsThis was a retrospective observational study. We evaluated 6-month outcomes for two groups seen and treated for an SRD between February 01, 2017 and January 31, 2020. Patient groups were comprised of N = 1363 PSC patients (Group A) and N = 1329 PC patients (Group B). We conducted Pearson chi-square and logistic regression (adjusting for patient characteristics that were unbalanced between the two groups) to determine associations between the two groups and 6-month outcomes.ResultsWithin six months of an initial visit for an SRD, a statistically significantly smaller proportion of PSC patients utilized healthcare resources for spine care as compared to the PC patients. When adjusting for patient characteristics, those who received care from the PSC clinician were less likely within 6 months of an initial visit to be hospitalized (OR = .47, 95% CI .23–.97), fill a prescription for an opioid analgesic (OR = .43; 95% CI .29–.65), receive a spinal injection (OR = .56, 95% CI .33–.95), or have a visit with a specialist (OR = .48, 95% CI .35–.67) as compared to those who received usual primary care.ConclusionsPatients who received PSC in an academic primary care clinic experienced significantly less escalation of their spine care within 6 months of their initial visit. The PSC model may offer a more efficient approach to the primary care of spine problems for patients with SRDs, as compared to usual primary care.

Efficacy of anakinra on rebound of multisystem inflammatory syndrome.

Efficacy of anakinra on rebound of multisystem inflammatory syndrome.

Delivering Urgent Elective Surgery at a COVID Clean Facility During Phase 1 of the UK Lockdown and Developing a Contingency Plan for Potential Future Waves

Background: The COVID-19 pandemic has resulted in unprecedented disruption in the delivery of elective surgical care and fears of ongoing waves exist. Our organisation explored a model of care to enable safe delivery of urgent elective surgical care for the diagnosis of cancer across various specialties. This study presents the results of this model and the development of a contingency plan for a future wave of the COVID-19 pandemic. Methods: Early on during phase-1 of the UK lockdown, a clean facility fit for purpose for delivering elective surgical care was identified and measures implemented to ensure safety across the process. Results: A total of 499 patients were booked between 20/03/2020 to 18/06/2020 (Phase-1), 44 were cancelled because 7 developed symptoms of COVID-19 pre-operatively, household members of 2 patients became symptomatic, 4 failed to attend and 31 were unsuitable due to co-morbidities. There was no mortality at 7 or 30 days. Twenty two patients developed complications post-operatively, 4 required escalation of care, 5 required transfer to the parent site, 13 were readmitted and 4 required a re-operation. None of the patients developed COVID-19 in the post-operative period up to 30 days. Thirty-one patients developed symptoms suggestive of COVID-19 all of whom tested negative on a swab test. Overall, patient satisfaction was good. Conclusion: It was possible to safely deliver urgent elective surgical care at a COVID clean facility in our population. This strategy may facilitate the continued delivery of urgent elective surgical care during potential further waves of COVID-19 pandemic or similar future health crisis.

PaO2 / FiO2 ratio responsiveness to prone positioning in intubated patients with severe COVID-19: a retrospective observational study.

AimProne positioning of coronavirus disease 2019 (COVID‐19) patients could improve oxygenation. However, clinical data on prone positioning of intubated COVID‐19 patients are limited. We investigated trends of PaO2 / FiO2 ratio values in patients during prone positioning to identify a predictive factor for early detection of patients requiring advanced therapeutic intervention such as extracorporeal membrane oxygenation (ECMO).MethodsThis retrospective, observational cohort study was undertaken between April 2020 and May 2021 in a tertiary referral hospital for COVID‐19 in Osaka, Japan. We included intubated adult COVID‐19 patients treated with prone positioning within the first 72 h of admission to the intensive care unit and followed them until hospital discharge or death. Primary outcomes were in‐hospital mortality and escalation of care to ECMO. We used unsupervised k‐means clustering modeling to categorize COVID‐19 patients by PaO2 / FiO2 ratio responsiveness to prone positioning.ResultsThe final study cohort comprised 54 of 155 consecutive severe COVID‐19 patients. Three clusters were generated according to trends in PaO2 / FiO2 ratios during prone positioning (cluster A, n = 16; cluster B, n = 24; cluster C, n = 14). Baseline characteristics of all clusters were almost similar. Cluster A (no increase in PaO2 / FiO2 ratio during prone positioning) had a significantly higher proportion of patients placed on ECMO or who died (6/16, 37.5%). Numbers of patients with ECMO and with in‐hospital death were significantly different between the three groups (p = 0.017).ConclusionIn Japanese patients intubated due to COVID‐19, clinicians should consider earlier escalation of treatment, such as facility transfer or ECMO, if the PaO2 / FiO2 ratio does not increase during initial prone positioning.

Can pediatric sleep questions be incorporated into a risk model to predict respiratory complications following adenotonsillectomy?

BackgroundAdenotonsillectomy, one of the most frequent surgical procedures in children, is usually performed for sleep-disordered breathing, a disease spectrum from primary snoring to obstructive sleep apnea. Children undergoing an adenotonsillectomy may be at risk for perioperative respiratory complications, necessitating intervention or escalation of care. However, there is no effective preoperative screening or risk-stratification model for perioperative respiratory complications that incorporates not only clinical history and physical examination but also sleep question responses for children as there is for adults. ObjectivesThe aim of this prospective observational study was to develop a risk-stratification model for perioperative respiratory complications in children undergoing an adenotonsillectomy incorporating not only clinical history and physical examination but also sleep question responses. MethodsA 25-question sleep questionnaire was prospectively administered preoperatively for 1895 children undergoing an adenotonsillectomy from November 2015 to December 2017. The primary outcome measure was overall perioperative respiratory complications, collected prospectively and defined as having at least one major or minor complication intraoperatively or postoperatively. ResultsThe incidence of overall perioperative respiratory complications was 20.4%. Preoperative factors associated with perioperative respiratory complications in the multiple regression model were age, race, preoperative tonsil size, the presence of a syndrome, and the presence of a pulmonary disease. None of the sleep questionnaire responses remained in the multivariable analysis. The area under the ROC curve for the risk stratification model incorporating sleep question responses was only 0.6114% (95% CI: 0.60, 0.67). ConclusionPreoperative sleep question responses may be unable to predict overall perioperative respiratory complications in children undergoing an adenotonsillectomy. A robust risk stratification model incorporating sleep question responses with clinical history and physical examination was unable to discriminate or predict perioperative respiratory complications in our population undergoing an adenotonsillectomy.

188 Community Simulation Program Designed to Improve Recognition of The Deteriorating Patient and Escalation of Care Pathways

This abstract looks at how we implemented physical health simulations within community hospitals in late 2020 and more recently physical health simulation in mental health units.The objectives of these simulations were to improve the recognition of deteriorating patients and the appropriate escalation and/or transfer of care as well as ‘identifying latent errors through simulation’ We have run simulations in the community since October 2020 and in the mental health units in February 2021. These sessions have covered four main themes: SepsisHypoglycaemiaAnaphylaxisOpioid overdoseThese sessions were taken from pre-existing incidents such as the hypoglycaemic relative and anaphylaxis. We also added opioid overdose as this topic is relevant to both mental health units and community hospitals. We delivered a package of four simulations across 1 month at each unit. This allowed for a different simulation each week, regular learning outcomes and wider opportunity of contact with the staff working within these areas. These sessions were always well attended with staff even committing to learning on days off. This level of commitment shows a real desire to improve not only their own knowledge but also patient safety. We engaged over 50 staff on 9 separate sites (five community hospitals, four mental health wards). Staff have been very engaging and have really got behind these simulation sessions as well as the ward managers. By engaging both mental and physical health, it has helped to provide a wider audience of staff and helped to gain a parity of esteem across the trust in the provision of safety training and simulation. We have also identified a number of latent errors such as non-standardized provision of anaphylaxis adrenalin across the trust, staff unfamiliar with resuscitation equipment bags and equipment location within and identifying the lack of Glucagon within a Hypo box.The data collected from these sessions have shown a growth in confidence in identifying deteriorating patients and how to correctly implement and use escalation tools such as the sepsis pathway, electronic observations (E-Obs), anaphylaxis algorithms and the SBAR communication tool.These simulations have really allowed us to bridge the gap between the acute and community site, allowing for a greater parity of esteem for all patients. Further steps in this program will be delivering mental health simulations to all mental health units and community hospitals to further bridge the learning between physical health and mental health.

What Is the Role of Shared Decision-Making With Parents of Children With Bronchiolitis?

What Is the Role of Shared Decision-Making With Parents of Children With Bronchiolitis?

A COVID-19 field hospital in a conference centre - The Cape Town, South Africa experience.

BackgroundThe coronavirus pandemic has put extreme pressure on health care services in South Africa.AimTo describe the design, patients and outcomes of a field hospital during the first wave of the coronavirus disease 2019 (COVID-19) pandemic.SettingThe Cape Town International Convention Centre was the first location in Cape Town to be commissioned as a field hospital that would serve as an intermediate care bed facility.MethodsThis was a retrospective descriptive study of patients admitted to this facility between 8th June 2020 and 14th August 2020 using deidentified data extracted from patient records.ResultsThere were 1502 patients admitted, 56.4% female, with a mean age of 58.6 years (standard deviation [s.d.]: 14.2). The majority of patients (82.9%) had at least one comorbidity, whilst 15.4% had three or more. Nearly 80.0% (79.8%) of patients required oxygen and 63.5% received steroids, and only 5.7% of patients were required to be transferred for escalation of care. The mean length of stay was 6 days (s.d.: 4.8) with an overall mortality of 5.7%.ConclusionThis study highlights the role of a field hospital in providing surge capacity. Its use halved the predicted duration of stay at acute care hospitals, allowing them the capacity to manage more unstable and critical patients. Adaptability and responsivity as well as adequate referral platforms proved to be crucial. Daily communication with the whole health care service platform was a critical success factor. This study provides information to assist future health planning and strategy development in the current pandemic and future disease outbreaks.

Care of older people and people requiring palliative care with COVID-19: guidance from the Australian National COVID-19 Clinical Evidence Taskforce.

IntroductionOlder people living with frailty and/or cognitive impairment who have coronavirus disease 2019 (COVID‐19) experience higher rates of critical illness. There are also people who become critically ill with COVID‐19 for whom a decision is made to take a palliative approach to their care. The need for clinical guidance in these two populations resulted in the formation of the Care of Older People and Palliative Care Panel of the National COVID‐19 Clinical Evidence Taskforce in June 2020. This specialist panel consists of nursing, medical, pharmacy and allied health experts in geriatrics and palliative care from across Australia.Main recommendationsThe panel was tasked with developing two clinical flow charts for the management of people with COVID‐19 who are i) older and living with frailty and/or cognitive impairment, and ii) receiving palliative care for COVID‐19 or other underlying illnesses. The flow charts focus on goals of care, communication, medication management, escalation of care, active disease‐directed care, and managing symptoms such as delirium, anxiety, agitation, breathlessness or cough. The Taskforce also developed living guideline recommendations for the care of adults with COVID‐19, including a commentary to discuss special considerations when caring for older people and those requiring palliative care.Changes in management as result of the guidelineThe practice points in the flow charts emphasise quality clinical care, with a focus on addressing the most important challenges when caring for older individuals and people with COVID‐19 requiring palliative care. The adult recommendations contain additional considerations for the care of older people and those requiring palliative care.

32. Host Immune-Protein Signature Combining TRAIL, IP-10 and CRP for Early and Accurate Prediction of Severe COVID-19 Outcome

BackgroundAccurately identifying COVID-19 patients at-risk to deteriorate remains challenging. Dysregulated immune responses impact disease progression and development of life-threatening complications. Tools integrating host immune-protein expression have proven useful in determining infection etiology and hold potential for prognosticating disease severity.MethodsAdults with COVID-19 were enrolled at medical centers in Israel, Germany, and the United States (Figure 1). Severe outcome was defined as intensive care unit admission, non-invasive or invasive ventilation, or death. Tumor necrosis factor related apoptosis inducing ligand (TRAIL), interferon gamma inducible protein-10 (IP-10) and C-reactive protein (CRP) were measured using an analyzer providing values within 15 minutes (MeMed Key®). A signature indicating the likelihood of severe outcome was derived generating a score (0-100).Description of derivation cohort RT-PCR, reverse transcription polymerase chain reaction.ResultsBetween March and November 2020, 518 COVID-19 patients were enrolled, of whom 394 were eligible, 29% meeting a severe outcome. Age ranged between 19-98 (median 61.5), with 59.1% male. Patients meeting severe outcomes exhibited higher levels of CRP and IP-10 and lower levels of TRAIL (Figure 2; p < 0.001). Likelihood of severe outcome increased significantly (p < 0.001) with higher scores. The signature’s area under the receiver operating characteristic curve (AUC) was 0.86 (95% confidence interval: 0.81-0.91). Performance was not confounded by age, sex, or comorbidities and was superior to IL-6 (AUC 0.77; p = 0.033) and CRP (AUC 0.78; p < 0.001). Clinical deterioration proximal to blood draw was associated with higher signature score. Scores of patients meeting a first outcome over 3 days after blood draw were significantly (p < 0.001) higher than scores of non-severe patients (Figure 3). Moreover, the signature differentiated patients who further deteriorated after meeting a severe outcome from those who improved (p = 0.004) and projected 14-day survival probabilities (p < 0.001; Figure 4).TRAIL, IP-10, CRP and the severity signature score are differentially expressed in severe and non-severe COVID-19 infection Dots represent patients and boxes denote median and interquartile range (IQR)The signature score of patients meeting a severe outcome on or after the day of blood draw is significantly (p < 0.001) higher than the signature score of non-severe patients. Dots represents patients and boxes denote median and IQRKaplan-Meier survival estimates for signature score bins ConclusionThe derived signature combined with a rapid measurement platform has potential to serve as an accurate predictive tool for early detection of COVID-19 patients at risk for severe outcome, facilitating timely care escalation and de-escalation and appropriate resource allocation. Disclosures Alon Angel, n/a, MeMed (Employee, Shareholder) Niv Samuel Mastboim, BSc, MeMed (Employee, Shareholder) Oded Shaham, PhD, MeMed (Employee, Shareholder) Tahel Ilan Ber, MD, MeMed (Employee, Shareholder) Roy Navon, MSc, MeMed (Employee, Shareholder) Einav Simon, PhD, MeMed (Employee, Shareholder) Michal Rosenberg, PhD, MeMed (Employee) Yael Israeli, PhD, MeMed (Employee) Mary Hainrichson, PhD, MeMed (Employee, Shareholder) Noa Avni, PhD, MeMed (Employee) Eran Reiner, MD, MeMed (Employee) Kfir Oved, MD, PhD, MeMed (Board Member, Employee, Shareholder) Ilya Kagan, MD, MeMed (Scientific Research Study Investigator) Shaul Lev, M.D, MeMed (Scientific Research Study Investigator) Dror Diker, MD, MeMed (Scientific Research Study Investigator) Amir Jarjou’i, MD, MeMed (Scientific Research Study Investigator) Ramzi Kurd, MD, MeMed (Scientific Research Study Investigator) Guy Danziger, MD, MeMed (Scientific Research Study Investigator) Cihan Papan, MD, MeMed (Scientific Research Study Investigator) Sergey Motov, MD, MeMed (Scientific Research Study Investigator) Maanit Shapira, Ph.D, MeMed (Scientific Research Study Investigator) Tanya Gottlieb, PhD, MeMed (Employee, Shareholder) Eran Eden, PhD, MeMed (Board Member, Employee, Shareholder)

Escalating Care on Labor and Delivery

Maternal morbidity and mortality are rising due in part to the rising prevalence of chronic illness, socioeconomic and racial disparities, and advanced maternal age. Prevention of maternal adverse outcomes requires prompt escalation of care to facilities with appropriate capabilities including intensive care services. The development of obstetrical-specific risk assessment tools and protocolized care for the most common causes of maternal intensive care unit (ICU) admission has helped to reduce preventable complications. However, significant work remains to address barriers to the escalation of maternal care and minimize delays in appropriate management.

A feed-centric hypoglycaemia pathway ensures appropriate care escalation in at-risk infants

BackgroundThere is a lack of clarity of what constitutes the starting point of a clinical pathway for infants at-risk of hypoglycaemia. Glucose-centric pathways (GCP) identify low glucose in the first...

Venomous Snake and Spider Bites in Pregnancy.

Venomous snake and spider bites are relatively rare in the Unites States and even more so in the pregnant population. However, the impact of a venomous bite, also known as an envenomation, can be serious in a pregnant patient. Thus, providers in endemic and high-risk areas must be familiar with the management of envenomation in the pregnant population. The purpose of this article is to review the current literature on the most common snake and spider envenomations in the United States, the effects of envenomation on maternal and fetal health, and the management of envenomation in pregnancy. Original research articles, review articles, and guidelines on snake and spider envenomation were reviewed. Snake envenomation carries higher risks of maternal morbidity and fetal morbidity and mortality than spider envenomation. Although the data are limited, current literature suggests that both snake and spider antivenom can be used in the pregnant population without significant adverse outcomes. However, the risks of an adverse hypersensitivity reaction with antivenom administration should be weighed carefully with the benefits. The use of antivenom therapy in the symptomatic envenomated pregnant population is likely safe with the appropriate monitoring and follow-up. Knowledge of the indications for antivenom therapy and proper escalation of care are vital to optimizing maternal and fetal outcomes. More research is needed to determine the effects of both envenomation and antivenom therapy on the pregnant patient and their fetus.

Assessment and management of itchy skin in pregnancy.

Women with rashes or itchy skin during pregnancy will often present initially to the general practitioner. Knowledge of thespecific dermatoses of pregnancy willassist in diagnosis, management and,importantly, facilitation of timely escalation of care of conditions that canpotentially affect the fetus. The aim of this article is to provide a diagnostic framework for approaching apruritic rash during pregnancy as well asa helpful summary of management ofpregnancy-specific dermatoses. It will assist clinicians in the identification of specific dermatoses that pose fetal risks. In addition to considering non-pregnancy specific conditions when approaching pruritus or a pruritic rash in pregnancy, it is important that clinicians also consider pregnancy-specific dermatoses, which have been reclassified into four categories: polymorphic eruption of pregnancy, pemphigoid gestationis, intrahepatic cholestasis of pregnancy (ICP) and atopic eruption of pregnancy. Unlike the other dermatoses, ICP begins with pruritus, and skin changes are secondary. ICP and pemphigoid gestationis are associated with fetal riskssuch as prematurity and stillbirth.

Utilization of Monitored Beds for Children Admitted With Unintentional Poisonings.

Children with unintentional poisonings (UPs) are frequently admitted to monitored beds (MBs), though most require minimal interventions. We aimed to (1) describe clinical factors and outcomes for children admitted for UPs and (2) identify clinical factors associated with MB placement. In this single-center retrospective cohort study, we studied patients younger than 6 years admitted from the emergency department (ED) for UPs over a 5-year period to a quaternary-care children's hospital. Primary outcome was disposition (MB vs non-MB). Secondary outcomes included length of stay, escalation of inpatient care, 7-day readmission, and death. Covariates included age, certainty of ingestion, altered mental status, and ED provider training level. Subanalysis of drug class effect on disposition was also studied. Associations of clinical factors with MB placement were tested with multivariable logistic regression. Of 401 patients screened, 345 subjects met inclusion criteria. Most subjects (308 of 345 [89%]) were admitted to MBs. Children with high certainty of ingestion (adjusted odds ratio [aOR], 4.2; 95% confidence interval [CI], 1.52-11.58), altered mental status (aOR, 5.82; 95% CI, 2.45-13.79), and a fellow (vs faculty) ED provider (aOR, 2.34; 95% CI, 1.04-5.24) were more likely to be admitted to MBs. No escalations of care, readmissions, or deaths occurred. Exposures to cardiac drugs had increased MB placement (aOR, 6.74; 95% CI, 1.93-23.59). The majority of children admitted for UPs were placed in MBs. Regardless of inpatient placement, no adverse events were observed, suggesting opportunities for optimized resource utilization. Future research may focus on direct costs, inpatient interventions, or prospective outcomes to validate these findings.

Outcomes of second-tier rapid response activations in a tertiary referral hospital: A prospective observational study

A second-tier rapid response team (RRT) is activated for patients who do not respond to first-tier measures. The premise of a tiered response is that first-tier responses by a ward team may identify and correct early states of deterioration or establish goals of care, thereby reducing unnecessary escalation of care to the RRT. Currently, utilisation and outcomes of tiered RRTs remain poorly described. A prospective observational study of adult patients (age ≥18 years) who required RRT activations was conducted from February 2018 to December 2019. There were 951 consecutive RRT activations from 869 patients and 76.0% patients had a National Early Warning Score (NEWS) ≥5 at the time of RRT activation. The majority (79.8%) of patients required RRT interventions that included endotracheal intubation (12.7%), point-of-care ultrasound (17.0%), discussing goals of care (14.7%) and intensive care unit (ICU) admission (24.2%). Approximately 1 in 3 (36.6%) patients died during hospitalisation or within 30 days of RRT activation. In multivariate analysis, age ≥65 years, NEWS ≥7, ICU admission, longer hospitalisation days at RRT activation, Eastern Cooperative Oncology Group performance scores ≥3 (OR [odds ratio] 2.24, 95% CI [confidence interval] 1.45-3.46), metastatic cancer (OR 2.64, 95% CI 1.71-4.08) and haematological cancer (OR 2.78, 95% CI 1.84-4.19) were independently associated with mortality. Critical care interventions and escalation of care are common with second-tier RRTs. This supports the need for dedicated teams with specialised critical care services. Poor functional status, metastatic and haematological cancer are significantly associated with mortality, independent of age, NEWS and ICU admission. These factors should be considered during triage and goals of care discussion.

Outcomes of Positive and Suspicious Findings in Clinical Computed Tomography Lung Cancer Screening and the Road Ahead.

RationaleFuture optimization of computed tomography (CT) lung cancer screening (CTLS) algorithms will depend on clinical outcomes data.ObjectivesTo report the outcomes of positive and suspicious findings in a clinical CTLS program.MethodsWe retrospectively reviewed results for patients from our institution undergoing lung cancer screening from January 2012 through December 2018, with follow-up through December 2019. All exams were retrospectively rescored using Lung-RADS v1.1 (LR). Metrics assessed included positive, probably benign, and suspicious exam rates, frequency/nature of care escalation, and lung cancer detection rates after a positive, probably benign, and suspicious exam result and overall. We calculated time required to resolve suspicious exams as malignant or benign. Results were broken down by subcategories, reason for positive/suspicious designation, and screening round.ResultsDuring the study period 4,301 individuals underwent a total of 10,897 exams. The number of positive (13.9%), suspicious (5.5%), and significant incidental (6.4%) findings was significantly higher at baseline screening. Cancer detection and false-positive rates were 2.0% and 12.3% at baseline versus 1.3% and 5.1% across subsequent screening rounds, respectively. Baseline solid nodule(s) 6 to <8 mm were the only probably benign findings resulting in lung cancer detection within 12 months. New solid nodules 6 to <8 mm were the only LR category 4A (LR4A) findings falling within the LR predicted cancer detection range of 5–15% (12.8%). 38.5% of LR4A cancers were detected within 3 months.ConclusionsModification of the definition and suggested workup of positive and suspicious lung cancer screening findings appears warranted.