Inpatient Deterioration Research Articles

Serum Markers of Blood-Brain Barrier Remodeling and Fibrosis as Predictors of Etiology and Clinicoradiologic Outcome in Intracerebral Hemorrhage.

Background: Intracerebral hemorrhage (ICH) is a stroke subtype associated with high disability and mortality. There is a clinical need for blood-based biomarkers that can aid in diagnosis, risk stratification, and prognostication. Given their role in the pathophysiology of ICH, we hypothesized markers of blood-brain barrier disruption and fibrosis would associate with neurologic deterioration and/or long-term functional outcomes. We also hypothesized these markers may be unique in patients with ICH due to cerebral amyloid angiopathy (CAA) vs. other etiologies.Methods: Seventy-nine patients enrolled in prospective ICH registries at two separate hospitals (the University of Texas Health Science Center at Houston and Hartford Hospital) were included in this study. We assessed initial injury severity and admission variables along with measures of inpatient deterioration (hematoma expansion, perihematomal edema (PHE), and early and delayed neurologic deterioration) and functional outcome [modified Rankin Scale (mRS) score at discharge and 90 days]. Serial biospecimens were obtained at 5 pre-specified timepoints (within 24 h, 1–2, 3–5, 6–8, and 10 days); serum samples were analyzed for fibronectin, all three TGF-β isoforms, and 7 matrix metalloproteinases (MMPs).Results: In our initial correlation analysis, MMP 10 and 3 were associated with hematoma expansion and early neurologic deterioration, whereas MMP 8 and MMP 1 were associated with PHE and delayed neurologic deterioration (respectively). Subacute levels of MMP 8 (sampled from day 6–10) positively correlated with PHE even after adjusting for multiple comparisons (p = 0.02). Acute levels of MMP 1, TGF-β1, and TGF-β3 were predictive of functional outcome, with TGF-β1 and TGF-β3 associating with 90 day mRS independent of age, hematoma volume, hemorrhage location, GCS, and IVH [p = 0.02; OR 1.03 (95% CI 1.0–1.05); p = 0.03; OR 3.1 (95% CI 1.1–8.8)]. When evaluated together as a panel, the cytokines distinguished patients with ICH due to CAA vs. ICH due to hypertension (AUC 0.81).Conclusions: Serum levels of fibronectin, TGF-β, and MMPs may be useful in refining ICH etiology and prognosis. Further large-scale studies are needed to confirm these findings, particularly regarding patients with CAA.

Improved outcomes after successful implementation of a pediatric early warning system (PEWS) in a resource-limited pediatric oncology hospital.

Hospitalized pediatric oncology patients are at high risk of clinical decline and mortality, particularly in resource-limited settings. Pediatric early warning systems (PEWS) aid in the early identification of clinical deterioration; however, there are limited data regarding their feasibility or impact in low-resource settings. This study describes the successful implementation of PEWS at the Unidad Nacional de Oncología Pediátrica (UNOP), a pediatric oncology hospital in Guatemala, resulting in improved inpatient outcomes. A modified PEWS was implemented at UNOP with systems to track errors, transfers to a higher level of care, and high scores. A retrospective cohort study was used to evaluate clinical deterioration events in the year before and after PEWS implementation. After PEWS implementation at UNOP, there was 100% compliance with PEWS documentation and an error rate of <10%. Implementation resulted in 5 high PEWS per week, with 30% of patients transferring to a higher level of care. Among patients requiring transfer to the pediatric intensive care unit (PICU), 93% had an abnormal PEWS before transfer. The rate of clinical deterioration events decreased after PEWS implementation (9.3 vs 6.5 per 1000-hospitalpatient-days, p = .003). Despite an 18% increase in total hospital patient-days, PICU utilization for inpatient transfers decreased from 1376 to 1088 PICU patient-days per year (21% decrease; P<.001). This study describes the successful implementation of PEWS in a pediatric oncology hospital in Guatemala, resulting in decreased inpatient clinical deterioration events and PICU utilization. This work demonstrates that PEWS is a feasible and effective quality improvement measure to improve hospital care for children with cancer in hospitals with limited resources. Cancer 2017;123:2965-74. © 2017 American Cancer Society.

Piloting electronic medical record-based early detection of inpatient deterioration in community hospitals.

Patients who deteriorate in the hospital outside the intensive care unit (ICU) have higher mortality and morbidity than those admitted directly to the ICU. As more hospitals deploy comprehensive inpatient electronic medical records (EMRs), attempts to support rapid response teams with automated early detection systems are becoming more frequent. We aimed to describe some of the technical and operational challenges involved in the deployment of an early detection system. This 2-hospital pilot, set within an integrated healthcare delivery system with 21 hospitals, had 2 objectives. First, it aimed to demonstrate that severity scores and probability estimates could be provided to hospitalists in real time. Second, it aimed to surface issues that would need to be addressed so that deployment of the early warning system could occur in all remaining hospitals. To achieve these objectives, we first established a rationale for the development of an early detection system through the analysis of risk-adjusted outcomes. We then demonstrated that EMR data could be employed to predict deteriorations. After addressing specific organizational mandates (eg, defining the clinical response to a probability estimate), we instantiated a set of equations into a Java application that transmits scores and probability estimates so that they are visible in a commercially available EMR every 6 hours. The pilot has been successful and deployment to the remaining hospitals has begun. Journal of Hospital Medicine 2016;11:S18-S24. © 2016 Society of Hospital Medicine.

Development and validation of an electronic medical record-based alert score for detection of inpatient deterioration outside the ICU

BackgroundPatients in general medical-surgical wards who experience unplanned transfer to the intensive care unit (ICU) show evidence of physiologic derangement 6–24h prior to their deterioration. With increasing availability of electronic medical records (EMRs), automated early warning scores (EWSs) are becoming feasible. ObjectiveTo describe the development and performance of an automated EWS based on EMR data. Materials and methodsWe used a discrete-time logistic regression model to obtain an hourly risk score to predict unplanned transfer to the ICU within the next 12h. The model was based on hospitalization episodes from all adult patients (18years) admitted to 21 Kaiser Permanente Northern California (KPNC) hospitals from 1/1/2010 to 12/31/2013. Eligible patients met these entry criteria: initial hospitalization occurred at a KPNC hospital; the hospitalization was not for childbirth; and the EMR had been operational at the hospital for at least 3months. We evaluated the performance of this risk score, called Advanced Alert Monitor (AAM) and compared it against two other EWSs (eCART and NEWS) in terms of their sensitivity, specificity, negative predictive value, positive predictive value, and area under the receiver operator characteristic curve (c statistic). ResultsA total of 649,418 hospitalization episodes involving 374,838 patients met inclusion criteria, with 19,153 of the episodes experiencing at least one outcome. The analysis data set had 48,723,248 hourly observations. Predictors included physiologic data (laboratory tests and vital signs); neurological status; severity of illness and longitudinal comorbidity indices; care directives; and health services indicators (e.g. elapsed length of stay). AAM showed better performance compared to NEWS and eCART in all the metrics and prediction intervals. The AAM AUC was 0.82 compared to 0.79 and 0.76 for eCART and NEWS, respectively. Using a threshold that generated 1 alert per day in a unit with a patient census of 35, the sensitivity of AAM was 49% (95% CI: 47.6–50.3%) compared to the sensitivities of eCART and NEWS scores of 44% (42.3–45.1) and 40% (38.2–40.9), respectively. For all three scores, about half of alerts occurred within 12h of the event, and almost two thirds within 24h of the event. ConclusionThe AAM score is an example of a score that takes advantage of multiple data streams now available in modern EMRs. It highlights the ability to harness complex algorithms to maximize signal extraction. The main challenge in the future is to develop detection approaches for patients in whom data are sparser because their baseline risk is lower.

Febrile neutropenia and refeeding syndrome

We describe the management of a 4-year-old child with acute lymphoblastic leukaemia (ALL) who presented with febrile neutropenia, Cryptosporidium and subsequently developed refeeding syndrome. Febrile neutropenia is common and can...

Effectiveness of respiratory rates in determining clinical deterioration: a systematic review protocol.

The objective of this systematic review is to identify, appraise and synthesize the best available evidence on the effectiveness of manually measuring respiratory rates for 60 s or less in detecting clinical deterioration of inpatients. More specifically, the review question is:Is measurement of respiratory rates for 60 s more effective in detecting clinical deterioration than a shorter duration of measurement?

Neural respiratory drive predicts clinical deterioration and safe discharge in exacerbations of COPD

RationaleHospitalised patients with acute exacerbation of COPD may deteriorate despite treatment, with early readmission being common.ObjectivesTo investigate whether neural respiratory drive, measured using second intercostal space parasternal muscle electromyography (EMGpara),...

Validation of the National Early Warning Score in the prehospital setting

BackgroundEarly intervention and response to deranged physiological parameters in the critically ill patient improves outcomes. A National Early Warning Score (NEWS) based on physiological observations has been developed for use throughout the National Health Service (NHS) in the UK. Although a good predictor of mortality and deterioration in inpatients, its performance in the prehospital setting is largely untested. This study aimed to assess the validity of the NEWS in unselected prehospital patients. MethodsAll clinical observations taken by emergency ambulance crews transporting patients to a single hospital were collated along with information relating to hospital outcome over a two month period. The performance of the NEWS in identifying the endpoints of 48h and 30 day mortality, intensive care unit (ICU) admission, and a combined endpoint of 48h mortality or ICU admission was analysed. Results1684 patients were analysed. All three of the primary endpoints and the combined endpoint were associated with higher NEWS scores (p<0.01 for each). The medium-risk NEWS group was associated with a statistically significant increase in ICU admission (RR=2.466, 95% CI 1.0–6.09), but not in-hospital mortality relative to the low risk group. The high risk NEWS group had significant increases in 48h mortality (RR 35.32 [10.08–123.7]), 30 day mortality (RR 6.7 [3.79–11.88]), and ICU admission (5.43 [2.29–12.89]). Similar results were noted when trauma and non-trauma patients were analysed separately. ConclusionsElevated NEWS among unselected prehospital patients is associated with a higher incidence of adverse outcomes. Calculation of prehospital NEWS may facilitate earlier recognition of deteriorating patients, early involvement of senior Emergency Department staff and appropriate critical care.

Predicting failure to improve during rehabilitation for older patients using routinely collected clinical data

ObjectiveEffective use of rehabilitation facilities for older people requires that those selected to undergo rehabilitation are best placed to benefit. We tested whether routinely collected clinical factors could predict deterioration or failure to improve during inpatient rehabilitation. MethodsAnalysis of prospectively collected routine clinical data from adults aged 65 and over, admitted to an inpatient rehabilitation between 1st January 1999 and 31st December 2008. Measures analysed were changed in 20-point Barthel score and indices of function including nutrition, swallow, communication and mental health between admission and discharge. Cut-off values for admission Barthel score were used to test which groups of patients would fail to improve further; admission indices of function, comorbidity and demographic information were combined in multivariable analyses to test which factors independently predicted failure to improve, deterioration or death during inpatient rehabilitation. ResultsThree thousand five hundred and seventy-two patients were included in the analyses, mean age 81.6 (SD 7.6) years. The mean admission Barthel score was 10.2 (SD 3.8). There was no admission Barthel score above which patients failed to improve either their Barthel score or other indices of function. In multivariate analyses, combinations of age, sex, admission Barthel score and other admission indices of function independently predicted inpatient death, death or deterioration, and death, deterioration or failure to improve on admission Barthel. The classification accuracy for all models was low at 70% or less. ConclusionsBarthel scores and indices of function do not accurately predict which older patients will fail to benefit from inpatient rehabilitation.

Patterns of Changes in Wheelchair Exercise Capacity After Spinal Cord Injury

Objectives(1) To identify different patterns of changes in wheelchair exercise capacity in the period between the start of active spinal cord injury (SCI) rehabilitation and 5 years after discharge; (2) to examine the pattern determinants of the change in wheelchair exercise capacity. DesignProspective cohort study. Measurements were recorded at the start of active inpatient rehabilitation, 3 months after the start, at discharge of inpatient rehabilitation, 1 year after discharge, and 5 years after discharge. SettingEight rehabilitation centers. ParticipantsPersons with SCI (N=130; age range, 18–65y), who were wheelchair-dependent, at least for long distances. InterventionsNot applicable. Main Outcome MeasureWheelchair exercise capacity: peak power output (W). ResultsWe found 4 different patterns of the change of peak power output (mean ± SD): (1) a pattern with high and progressive scores (33% of total study group): high progressive scores (start of rehabilitation: 49±15W to 5 years after discharge: 77±17.2W); (2) a pattern of improvement during inpatient rehabilitation and deterioration after inpatient rehabilitation (12%): progressive scores during inpatient rehabilitation with deteriorating scores after discharge (start of rehabilitation: 29±8.7W, to discharge: 60±8.4W, to 5 years after discharge: 39±13.1W); (3) a pattern with low and only slightly progressive scores (52%): low progressive scores (start of rehabilitation: 20±10.1W to 5 years after discharge: 31±15.9W); and (4) a pattern with low scores during inpatient rehabilitation and a sharp rise after discharge (3%): low inpatient scores with strong progressive scores after discharge (start of rehabilitation: 29±15.5W to 5 years after discharge: 82±10.6W). A logistic regression of factors that may distinguish between patterns with high and progressive scores and patterns with low and only slightly progressive scores revealed that older age, being a woman, having a tetraplegic lesion, and low functional status were associated with patterns with low and only slightly progressive scores. The pattern of improvement during inpatient rehabilitation and deterioration after inpatient rehabilitation showed more neuropathic pain and lower sports participation than patterns with high and progressive scores. ConclusionsFor the vast majority of patients, wheelchair exercise capacity after SCI shows a positive trend and can be described in distinct patterns that are dependent on personal, lesion, and functional characteristics.

A trial of a real‐time Alert for clinical deterioration in Patients hospitalized on general medical wards

With limited numbers of intensive care unit (ICU) beds available, increasing patient acuity is expected to contribute to episodes of inpatient deterioration on general wards. To prospectively validate a predictive algorithm for clinical deterioration in general-medical ward patients, and to conduct a trial of real-time alerts based on this algorithm. Randomized, controlled crossover study. Academic center with patients hospitalized on 8 general wards between July 2007 and December 2011. Real-time alerts were generated by an algorithm designed to predict the need for ICU transfer using electronically available data. The alerts were sent by text page to the nurse manager on intervention wards. Intensive care unit transfer, hospital mortality, and hospital length of stay. Patients meeting the alert threshold were at nearly 5.3-fold greater risk of ICU transfer (95% confidence interval [CI]: 4.6-6.0) than those not satisfying the alert threshold (358 of 2353 [15.2%] vs 512 of 17678 [2.9%]). Patients with alerts were at 8.9-fold greater risk of death (95% CI: 7.4-10.7) than those without alerts (244 of 2353 [10.4%] vs 206 of 17678 [1.2%]). Among patients identified by the early warning system, there were no differences in the proportion of patients who were transferred to the ICU or who died in the intervention group as compared with the control group. Real-time alerts were highly specific for clinical deterioration resulting in ICU transfer and death, and were associated with longer hospital length of stay. However, an intervention notifying a nurse of the risk did not result in improvement in these outcomes.

Developing a Continuous Monitoring Infrastructure for Detection of Inpatient Deterioration

A physiologic database infrastructure, composed of a patient monitoring system and a data processing and storage system, enables the detection of deterioration in noncritical patients, thereby helping to prevent failure-to-rescue events.

Use of a laboratory only score system to define trajectories and outcomes of older people admitted to the acute hospital as medical emergencies

Increasing numbers of older people are admitted to hospital as medical emergencies. They are a heterogeneous population with uncertain trajectories and outcomes. Our aim was to retrospectively characterize subgroups of older inpatients based on their acuity trajectories. This was a single-center patient series from St James's Hospital Dublin, Ireland (2002-2010). The Medical Admissions Risk System (MARS) score was used to classify a sample of 14,607 patients aged ≥ 65 years, from admission to end of episode, into four trajectory groups: (i) static high acuity (group 1); (ii) static low acuity (group 2); (iii) inpatient deterioration (group 3); and (iv) inpatient improvement (group 4). K-means cluster analysis was used for the classification. Group 1 (4.1%): median length of stay (LOS) 7.4 days, 23.6% used intensive care, mortality rate 79.2%; sepsis and renal failure were the dominant features. Group 2 (76.6%): median LOS 8.0 days, 5.2% used intensive care, mortality rate 9.5%; younger age, low comorbidity and diseases of non-vital organs were predominant. Group 3 (7.6%): median LOS 17.2 days, 17.4% used intensive care, mortality rate 76.1%; high comorbidity and sepsis/respiratory disease featured. Group 4 (11.7%): median LOS 12.1 days, 12.8% used intensive care, mortality rate 22.7%; sepsis and renal/metabolic disease were frequent, and comorbidity levels were intermediate. In older acute medical inpatients, the outcome seemed more driven by specific diagnoses (such as sepsis and renal failure) and comorbidity, than by age. Using the MARS score to retrospectively categorize older inpatients might help to understand their heterogeneity and promote the design of appropriate care pathways.

PWE-289 Critical illness early warning scores retain accuracy in patients with liver disease—an analysis of 182 000 inpatient observation sets

IntroductionAggregate weighted track and trigger systems (AWTTS) can identify critically ill patients at high risk of mortality. However, these scores use features of the Systemic Inflammatory Response Syndrome (SIRS) that...

Risk factors for medical deterioration of psychiatric inpatients: opportunities for early recognition and prevention

BackgroundMedical deterioration during admission to free-standing psychiatric hospitals is distressing for patients, interrupts bio-behavioral interventions, and places a substantial burden on health care resources. Emergency transfers to a general hospital are a reasonable marker of significant medical deterioration, but have not been assessed systematically. ObjectiveTo use clinical data available at the time of psychiatric admission to identify risk factors for transfers to a general hospital. MethodRetrospective review of the hospital course of 1000 adults consecutively admitted for an average of 19.1 ± 21.3 days to a single free-standing psychiatric hospital in 2010. ResultsOne hundred forty-four patients (14.4%) were transferred to a general hospital. Transferred and not-transferred groups differed significantly with regard to age, presence of dementia, number of comorbid medical disorder, history of arterial hypertension, blood urea nitrogen (BUN), creatinine, albumin, glucose, calcium, hemoglobin, and hematocrit (P < .001). In a multiple logistic regression analysis, blood urea nitrogen (odds ratio [OR], 63.2), hemoglobin (OR, 35.3), albumin (OR, 7.3) and age (OR, 5.73) were independently associated with transfers. Acute medical deteriorations occurred in 46.2% of patients with azotemia (BUN >24 mg/dL), 32.7% of those with anemia (Hb <12 g/L), 37.5 % of those with hypoalbuminemia (albumin <3.7 g/dL), and 37.4% of patients 65 and older. ConclusionMedical deterioration of psychiatric inpatients correlates with higher BUN, lower albumin and hemoglobin, and older age. Baseline azotemia, anemia or hypoalbuminemia should trigger prompt medical evaluation and enhanced monitoring to prevent, identify, and treat somatic disorders.

Clinical deterioration in hospital inpatients: the need for another paradigm shift

Clinical deterioration in hospital inpatients: the need for another paradigm shift

Introduction of a new observation chart and education programme is associated with higher rates of vital-sign ascertainment in hospital wards

IntroductionLocal and national awareness of the need to improve the recognition and response to the clinical deterioration of hospital inpatients is high. The authors designed and implemented a programme to...

ViEWS—Towards a national early warning score for detecting adult inpatient deterioration

Aim of study To develop a validated, paper-based, aggregate weighted track and trigger system (AWTTS) that could serve as a template for a national early warning score (EWS) for the detection of patient deterioration. Materials and methods Using existing knowledge of the relationship between physiological data and adverse clinical outcomes, a thorough review of the literature surrounding EWS and physiology, and a previous detailed analysis of published EWSs, we developed a new paper-based EWS – VitalPAC™ EWS (ViEWS). We applied ViEWS to a large vital signs database ( n = 198,755 observation sets) collected from 35,585 consecutive, completed acute medical admissions, and also evaluated the comparative performance of 33 other AWTTSs, for a range of outcomes using the area under the receiver-operating characteristics (AUROC) curve. Results The AUROC (95% CI) for ViEWS using in-hospital mortality with 24 h of the observation set was 0.888 (0.880–0.895). The AUROCs (95% CI) for the 33 other AWTTSs tested using the same outcome ranged from 0.803 (0.792–0.815) to 0.850 (0.841–0.859). ViEWS performed better than the 33 other AWTTSs for all outcomes tested. Conclusions We have developed a simple AWTTS – ViEWS – designed for paper-based application and demonstrated that its performance for predicting mortality (within a range of timescales) is superior to all other published AWTTSs that we tested. We have also developed a tool to provide a relative measure of the number of “triggers” that would be generated at different values of EWS and permits the comparison of the workload generated by different AWTTSs.

The deterioration of children in ward areas in a specialist children’s hospital

Research in adult patients, in the last decade, has highlighted suboptimal care and failures in the recognition of sick adults in ward areas. In addition, many of these patients (at least 50%) demonstrated documented evidence, on observation charts, of clinical deterioration in the 24-48 h preceding cardiopulmonary arrest or emergency intensive care unit admission. However, there is little published data on whether these findings apply to children (0-17 years). The aim of the study was to examine the extent of inpatient deterioration and critical care unit admission within a children's hospital based in the North West of England, during a 4-month period. The design included a prospective chart review of clinical observations. As noted in adult patients, there is considerable documented evidence (in terms of abnormal vital signs) of physiological deterioration in the 24 h preceding intensive care or high-dependency unit admission. The use of a Paediatric Early Warning (PEW) tool could potentially have identified 87% of these children of being 'at risk' of deterioration. It is recommended that a PEW tool be incorporated into the routine paediatric ward observation charts and practice to identify children 'at risk' of deterioration.