Intensive Care Unit Transfer Rates Research Articles

CT-Severity Analysis of Covid-19 Pneumonia in Rheumatic Musculoskeletal Diseases

Objectives: This study aims to focus on the radiological severity of covid-19 pneumonia in patients with rheumatic musculoskeletal diseases (RMD). Materials and Methods: A total of 342 Polymerase Chain Reaction positive patients were retrospectively reviewed. The patients were divided into two groups in terms of the presence of RMD. Chest Computed Tomography (CT) severity scores, demographic characteristics, hospitalization, intensive care unit (ICU) requirement, length of stay at the hospital were compared between RMD and non-RMD groups. Typical and atypical findings on CT images were identified with their incidence in both groups of patients. Results: Age and female gender were significantly higher in the RMD group (p=0.001, p=0.041). The average CT-severity score was higher in the RMD group, but the difference was not statistically significant (p=0.081). ICU transfer and mortality rates were higher in the RMD, whereas no difference was found in hospitalization rates and length of stay (p=0.002, p=0.036, p=0.280, p=0.168). Ground glass opacities, superimposed consolidation, and crazy paving patterns were the most common typical findings seen on both groups. Atypical CT findings for covid-19 pneumonia were found to be higher in the RMD group than in the non-RMD group. Conclusion: Chronic inflammation and the use of immunosuppressive drugs constitute a vulnerability to infections in RMD patients. In this study, mortality and ICU requirements were found to be higher in patients with RMD. Similarly, the higher rate of atypical chest CT findings in the RMD group may be of particular importance in the diagnosis and differential diagnosis of covid-19 pneumonia in this patient group. © 2021 Ankara Yildirim Beyazit University. All Rights Reserved.

Abstract 17393: Sex Differences in COVID-19 Hospitalization and Mortality in Chicagoland

Introduction: The novel coronavirus disease 2019 (COVID-19) pandemic has affected millions of people worldwide. Higher COVID-19 mortality in men compared to women seen in many countries is not yet explained. We analyzed sex differences in COVID-19 outcomes in a large Illinois-based cohort. Methods: This is a multicenter retrospective cohort study of confirmed COVID-19 infections from March 1–June 3, 2020 in Rush University System. We compared men and women with COVID-19 infection for the rates of hospitalization, intensive care unit (ICU) admission, vasopressor use, endotracheal intubation, and death. A multivariable model correcting for age, race, and sum of comorbidities (obesity, hypertension, diabetes, coronary artery disease, heart failure, end-stage renal disease, asthma, chronic obstructive pulmonary disease, active smoking) was used to determine independent association with outcomes. Results: Of the 8,086 patients who tested positive, 4,267 (53%) were females, while 3,819 (47%) were males. Males had a higher rate of hospitalization (19% vs. 14%; p<0.001), ICU transfer (8% vs. 4%; p<0.001), vasopressor support (4% vs. 2%; p<0.001), or endotracheal intubation (5% vs. 2%; p<0.001). Of the 132 patients who died (10% of hospitalized patients), 76 were males, while 56 were females (2% vs. 1%; p=0.018). The prevalence of active smoking, coronary artery disease, end-stage renal disease, and HIV were higher in males, while hypertension and asthma were more common in females. Multivariable model correcting for age, race, and sum of comorbidities showed a significant association between male sex and in-hospital mortality (OR 1.78; 95% CI 1.23-2.58; p=0.002). Conclusions: There were more women who tested positive for COVID-19 disease. Male sex was independently associated with higher rates of death, hospitalization, ICU admissions, need for vasopressors or endotracheal intubation, after correction for important covariates. The interplay of biological and and behavioral factors is likely responsible for the worse outcomes observed in men with COVID-19 infection. Further investigations into the pathophysiology of sex differences in COVID-19 outcomes responses are needed.

Absolute Eosinophil Count Predicts Intensive Care Unit Transfer Among Elderly COVID-19 Patients From General Isolation Wards.

Objectives: As of June 1, 2020, coronavirus disease 2019 (COVID-19) has caused a global pandemic and resulted in over 370,000 deaths worldwide. Early identification of COVID-19 patients who need to be admitted to the intensive care unit (ICU) helps to improve the outcomes. We aim to investigate whether absolute eosinophil count (AEC) can predict ICU transfer among elderly COVID-19 patients from general isolation wards.Methods: A retrospective study of 94 elderly patients older than 60 years old with COVID-19 was conducted. We compared the basic clinical characteristics and levels of inflammation markers on admission to general isolation wards and the needs for ICU transfer between the eosinopenia (AEC on admission <20 cells/μl) and non-eosinopenia (AEC ≥20 cells/μl) groups.Results: There was a significantly higher ICU transfer rate in the eosinopenia group than in the non-eosinopenia group (51 vs. 9%, P < 0.001). Multivariate analysis revealed that eosinopenia was associated with an increased risk of ICU transfer in elderly COVID-19 patients [adjusted odds ratio (OR) 6.12 (95% CI, 1.23–30.33), P = 0.027] after adjustment of age, lymphocyte count, neutrophil count, C-reactive protein (CRP), and ferritin levels. The eosinopenia group had higher levels of CRP, ferritin, and cytokines [interleukin-2 receptor (IL-2R), interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-10 (IL-10), and tumor necrosis factor-α (TNF-α)] than the non-eosinophil group (P < 0.001). The area under the curve of AEC on admission for predicting ICU transfer among elderly COVID-19 patients was 0.828 (95% CI, 0.732–0.923). The best cut-off value of AEC was 25 cells/μl with a sensitivity of 91% and a specificity of 71%, respectively.Conclusion: Absolute eosinophil count on admission is a valid predictive marker for ICU transfer among elderly COVID-19 patients from general isolation wards and, therefore, can help case triage and optimize ICU utilization, especially for health care facilities with limited ICU capacity.

The Use of Rapid Response Teams to Reduce Failure to Rescue Events: A Systematic Review.

ObjectiveThe aim of this systematic review was to synthesize the evidence on the impact of rapid response teams (RRTs) on failure to rescue events.MethodsSystematic searches were conducted using CINAHL, MEDLINE, PsychINFO, and Cochrane, for articles published from 2008 to 2018. English-language, peer-reviewed articles reporting the impact of RRTs on failure to rescue events, including hospital mortality and in-hospital cardiac arrest events, were included. For selected articles, the authors abstracted information, with the study designed to be compliant with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.ResultsTen articles were identified for inclusion: 3 meta-analyses, 3 systematic reviews, and 4 single studies. The systematic reviews and meta-analyses were of moderate-to-high quality, limited by the methodological quality of the included individual studies. The single studies were both observational and investigational in design. Patient outcomes included hospital mortality (8 studies), in-hospital cardiac arrests (9 studies), and intensive care unit (ICU) transfer rates (5 studies). There was variation in the composition of RRTs, and 4 studies conducted subanalyses to examine the effect of physician inclusion on patient outcomes.ConclusionsThere is moderate evidence linking the implementation of RRTs with decreased mortality and non-ICU cardiac arrest rates. Results linking RRT to ICU transfer rates are inconclusive and challenging to interpret. There is some evidence to support the use of physician-led teams, although evaluation of team composition was variable. Lastly, the benefits of RRTs may take a significant period after implementation to be realized, owing to the need for change in safety culture.

Antibiotics for Aspiration Pneumonia in Neurologically Impaired Children.

To compare hospital outcomes associated with commonly used antibiotic therapies for aspiration pneumonia in children with neurologic impairment (NI). A retrospective study of children with NI hospitalized with aspiration pneumonia at 39 children's hospitals in the Pediatric Health Information System database. Exposure was empiric antibiotic therapy classified by antimicrobial activity. Outcomes included acute respiratory failure, intensive care unit (ICU) transfer, and hospital length of stay (LOS). Multivariable regression evaluated associations between exposure and outcomes and adjusted for confounders, including medical complexity and acute illness severity. In the adjusted analysis, children receiving Gram-negative coverage alone had two-fold greater odds of respiratory failure (odds ratio [OR] 2.15; 95% CI: 1.41-3.27), greater odds of ICU transfer (OR 1.80; 95% CI: 1.03-3.14), and longer LOS [adjusted rate ratio (RR) 1.28; 95% CI: 1.16-1.41] than those receiving anaerobic coverage alone. Children receiving anaerobic and Gram-negative coverage had higher odds of respiratory failure (OR 1.65; 95% CI: 1.19-2.28) than those receiving anaerobic coverage alone, but ICU transfer (OR 1.15; 95% CI: 0.73-1.80) and length of stay (RR 1.07; 95% CI: 0.98-1.16) did not statistically differ. For children receiving anaerobic, Gram-negative, and P. aeruginosa coverage, LOS was shorter (RR 0.83; 95% CI: 0.76-0.90) than those receiving anaerobic coverage alone; odds of respiratory failure and ICU transfer rates did not significantly differ. Anaerobic therapy appears to be important in the treatment of aspiration pneumonia in children with NI. While Gram-negative coverage alone was associated with worse outcomes, its addition to anaerobic therapy may not yield improved outcomes.

Postoperative care in an intermediate-level medical unit after head and neck microvascular free flap reconstruction.

ObjectiveThe need for intensive care unit (ICU) admission and mechanical ventilation after head and neck microvascular free flap reconstructive surgery remains controversial. Our institution has maintained a longstanding practice of immediately taking patients off mechanical ventilation with subsequent transfer to intermediate, non‐ICU level of care with specialized otolaryngologic nursing. Our objective was to describe postoperative outcomes for a large cohort of patients undergoing this protocol and to examine the need for routine ICU transfer.Materials and MethodsWe performed a retrospective review of 512 consecutive free flaps treated with a standard protocol of immediate postoperative transfer to an intermediate‐level care unit with specialized otolaryngology nursing. Outcome measures included ICU transfer, ventilator requirement, flap failure, postoperative complications, and length of stay. Predictors of ICU transfer were identified by multivariable logistic regression.ResultsThe vast majority of patients did not require intensive care. Only a small fraction (n = 18 patients, 3.5%) subsequently transferred to the ICU, most commonly for respiratory distress, cardiac events, and infection. The most common complications were delirium/agitation (n = 55; 10.7%) and pneumonia (n = 51; 10.0%). Sixty‐five cases (12.7%) returned to the OR, most commonly for hematoma/bleeding (n = 41; 8.0%) and anastomosis revision (n = 20; 3.9%). Heavy alcohol consumption and greater number of medical comorbidities were significant predictors of subsequent ICU transfer.ConclusionsAmong head and neck free flap patients, routine cessation of mechanical ventilation and transfer to intermediate‐level care with specialized ENT nursing was found to be safe with infrequent subsequent ICU transfer and low complication rates. Routine transfer to intermediate‐level care in this population may prevent unnecessary ICU utilization and facilitate the delivery of high‐value, disease‐centered care.Level of Evidence3b

Bundle of care for blunt chest trauma patients improves analgesia but increases rates of intensive care unit admission: A retrospective case-control study

IntroductionThis single-centre retrospective case-control study aimed to assess the effectiveness of a multidisciplinary clinical pathway for blunt chest trauma patients admitted in emergency department (ED). Patients and methodsAll consecutive blunt chest trauma patients with more than 3 rib fractures and no indication of mechanical ventilation were compared to a retrospective cohort over two 24-month periods, before and after the introduction of the bundle of care. Improvement of analgesia was the main outcome investigated in this study. The secondary outcomes were the occurrence of secondary respiratory complications (pneumonia, indication for mechanical ventilation, secondary ICU admission for respiratory failure or death), the intensive care unit (ICU) and hospital length of stay (LOS). ResultsSixty-nine pairs of patients were matched using a 1:1 nearest neighbour algorithm adjusted on age and indices of severity. Between the two periods, there was a significant reduction of the rate of uncontrolled analgesia (55 vs. 17%, P<0.001). A significant increase in the rate of primary ICU transfer during the post-protocol period (23 vs. 52%, P<0.001) was not associated with a reduction of secondary respiratory complications or a reduction of ICU or hospital LOS. Only the use of non-steroidal anti-inflammatory drugs appeared to be associated with a significant reduction of secondary respiratory complications (OR=0.3 [0.1–0.9], P=0.03). ConclusionImplementation of a multidisciplinary clinical pathway significantly improves pain control after ED management, but increases the rate of primary ICU admission without significant reduction of secondary respiratory complications.

Improvements in Patient and Health System Outcomes Using an Integrated Oncology and Palliative Medicine Approach on a Solid Tumor Inpatient Service.

Early palliative care (PC) improves outcomes for outpatients with advanced cancer. Its effect on hospitalized patients with cancer is unknown. Herein, we report on the influence of a novel, fully integrated inpatient medical oncology and PC partnership at a tertiary medical center during its first year of implementation. We conducted a retrospective, longitudinal, pre- and postintervention cohort study at Duke University Hospital. Pre- and postintervention cohorts were defined as all patients admitted to the solid tumor inpatient service from September 1, 2009, to June 30, 2010, and September 1, 2011 to June 30, 2012, respectively. We extracted patient data, including demographics, cancer diagnosis, disease status, length of stay, intensive care unit transfer rate, discharge disposition, time to emergency department return, time to readmission, and 7- and 30-day emergency department return and readmission rates. Nursing and physician surveys assessed satisfaction. Descriptive statistics, and Kruskal-Wallis and Χ2 tests were used to describe and compare cohorts. A generalized estimating equation accounted for repeated measures. Pre- and postintervention analysis cohorts included 731 and 783 patients, respectively, representing a total of 1,514 patients and 2,353 encounters. Cohorts were similar in baseline characteristics. Statistically significant lower odds in 7-day readmission rates were observed in the postintervention cohort (adjusted odds ratio, 0.76; 95% CI, 0.58 to 1.00; P = .0482). Patients in the postintervention group had a decrease in mean length of stay (-0.30 days; 95% CI, -0.62 to 0.02); P = .0651). We observed a trend for increasing hospice referrals ( P = .0837) and a 15% decrease in intensive care unit transfers ( P = .61). Physicians and nurses universally favored the model. A fully integrated inpatient partnership between PC and medical oncology is associated with significant and clinically meaningful improvements in key health system-related outcomes and indicators of quality cancer care.

Different characteristics associated with intensive care unit transfer from the medical ward between patients with acute exacerbations of chronic obstructive pulmonary disease with and without pneumonia.

The rate of hospitalization due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is increasing. Few studies have examined the clinical, laboratory and treatment differences between patients in general wards and those who need transfer to an intensive care unit (ICU). We retrospectively reviewed clinical, laboratory, and treatment characteristics of 374 patients who were initially admitted to the general ward at Chonnam National University Hospital in South Korea due to AECOPD (pneumonic, 194; non-pneumonic, 180) between January 2008 and March 2015. Of these patients, 325 were managed at the medical ward during their hospitalization period (ward group), and 49 required ICU transfer (ICU group). We compared the clinical, laboratory, and treatment characteristics associated with ICU transfer between patients with AECOPD with and without pneumonia. Male patients were 86.5% in the ward group and 79.6% in the ICU group. High glucose levels [median 154.5 mg/dL, interquartile range (IQR) 126.8-218.3 in ICU group vs. median 133.0, IQR 109.8-160.3 in ward group], high pneumonia severity index scores (median 100.5, IQR 85.5-118.5 vs. median 86.0, IQR 75.0-103.5), low albumin levels (median 2.9 g/dL, IQR 2.6-3.6 vs. median 3.4, IQR 3.0-3.7), and anemia (73.3% vs. 43.3%) independently increased the risk of ICU transfer in the pneumonic AECOPD group. High PaCO2 levels (median 53.1 mmHg in ICU group, IQR 38.5-84.6 vs. median 39.7, IQR 34.2-48.6 in ward group) independently increased the risk of ICU transfer in the non-pneumonic AECOPD group. Treatment with systemic corticosteroids (≥30 mg of daily prednisolone) during hospitalization in the medical ward independently reduced the risk of ICU transfer in both groups. The characteristics associated with ICU transfer differed between the pneumonic and non-pneumonic AECOPD groups, and systemic corticosteroids use was associated with lower rate of ICU transfer in both groups.

Patient Outcomes when Housestaff Exceed 80 Hours per Week

BackgroundIt has been posited that high workload and long work hours for trainees could affect the quality and efficiency of patient care. Duty hour restrictions seek to balance patient care and resident education by limiting resident work hours. Through a retrospective cohort study, we investigated whether patient care on an inpatient general medicine service at a large academic medical center is impacted when housestaff work more than 80 hours per week. MethodsWe identified all admissions to a housestaff-run general medicine service between June 25, 2013 and June 29, 2014. Each hospitalization was classified by whether the patient was admitted by housestaff who have worked more than 80 hours per week during their hospitalization. Housestaff computer activity and duty hours were calculated by institutional electronic heath record audit, as well as length of stay and a composite of in-hospital mortality, intensive care unit (ICU) transfer rate, and 30-day readmission rate. ResultsWe identified 4767 hospitalizations by 3450 unique patients; of which 40.9% of hospitalizations were managed by housestaff who worked more than 80 hours that week during their hospitalization. There was a significantly higher rate of the composite outcome (19.2% vs 16.7%, P = .031) for patients admitted by housestaff working more than 80 hours per week during their hospitalization. We found a statistically significant higher length of stay (5.12 vs 4.66 days, P = .048) and rate of ICU transfer (3.53% vs 2.38%, P = .029). There was no statistically significant difference in 30-day readmission rate (13.7% vs 12.8%, P = .395) or in-hospital mortality rate (3.18% vs 2.42%, P = .115). There was no correlation with team census on admission and patient outcomes. ConclusionsPatients taken care of by housestaff working more than 80 hours per week had increased length of stay and number of ICU transfers. There was no association between resident work-hours and patient in-hospital mortality or 30-day readmission rate.

High-Fidelity Simulation Effect on Nurses' Identification of Deteriorating Pediatric Patients

BackgroundWe evaluated the effects of high-fidelity pediatric simulation experiences on nurses' early recognition of deterioration and patient outcomes. MethodPediatric nurses (n = 83) participated in a 12-month quality improvement project. ResultsAmong 92 rapid response team/Code Blue events, 72.2% resulted in pediatric intensive care unit transfers; 84.8% of nurses' prior Pediatric Early Warning Score scores were accurate. The number of simulations that nurses completed during the study was not related to Pediatric Early Warning Score accuracy or pediatric intensive care unit transfer rates. ConclusionsAlthough simulations did not affect these outcomes, this is the first study to link pediatric high-fidelity simulation experiences to individual nurses' clinical decision-making practices and patient outcomes.

Early Enteral Nutrition and Aggressive Fluid Resuscitation are Associated with Improved Clinical Outcomes in Acute Pancreatitis

To determine whether recommendations for treatment of acute pancreatitis (AP) in adults impact the outcomes of pediatric AP. Adult guidelines regarding early management of AP were implemented through an admission order set at Cincinnati Children's Hospital Medical Center at the beginning of the year 2014. Recommendations included administering high rates of intravenous fluid (IVF) within 24 hours of admission and enteral nutrition within 48 hours of admission. A retrospective chart review of AP admissions before and after the implementation of the recommendations was undertaken. Outcomes studied were: hospital length of stay, intensive care unit transfer rates, development of severe AP, pulmonary complications, and readmission rates post discharge from the hospital. The study included 201 patients. Children who received feeds within the first 48 hours and received greater than maintenance IVF within 24 hours had a shorter length of stay, less intensive care unit admissions and severe AP rates compared with the patients who remained nil per os during the first 48 hours and received lower rates of IVF. Our data support that early enteral nutrition and early aggressive IVF improve outcomes of pediatric AP.

Mo1416 Outcomes of Post-ERCP Pancreatitis Have Not Improved Over the Past Decade

statistically significant. Conclusions: Incidence of post-ERCP pancreatitis does not differ at academic institutions depending on the time of year. However, LOS and total hospital charge do decrease throughout the academic year, suggesting the existence of a temporal effect. These differences may be explained by the influx of new medical trainees, on whom teaching hospitals depend for the bulk of their staffing, and further investigation is warranted. Mo1416 Outcomes of Post-ERCP Pancreatitis Have Not Improved Over the Past Decade Allison R. Schulman*, Marwan Abou Gergi, Marvin Ryou, Christopher C. Thompson Division of Gastroenterology, Brigham & Women, Boston, MA; Catalyst Medical Consulting, Towson, MD Introduction: Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Over the past several years, routine use of rectally administered nonsteroidal anti-inflammatory drugs (NSAIDs) and prophylactic pancreatic stent placement in high risk patients have been utilized in an attempt to mitigate this complication. Aims: To compare outcomes of post-ERCP pancreatitis over the past decade (2002-2012) including overall incidence, mortality, intensive care unit (ICU) transfer rate, length of stay (LOS) and attributable total charge. Methods: The Nationwide Inpatient Sample (NIS) database was used to calculate outcomes in 2012, 2010, 2007, 2004 and 2002. Discharges with an ICD-9 CM procedure code indicating ERCP and a secondary ICD-9 CM code for acute pancreatitis were included. Patients were excluded if they had a principal diagnosis of acute pancreatitis or if the ERCP was performed before or on the day of admission. The primary outcome was incidence of post-ERCP pancreatitis. Secondary outcomes were in hospital mortality, ICU transfer rate, additional LOS and attributable total charge. All charges were adjusted for inflation using the consumer price index. Total disease burden was calculated by multiplying the total number of patients by the mean attributable total charge per hospitalization. LOS and charge were adjusted for the following potential confounders using a multivariable regression model: age, sex, race, median income in the patient’s zip code, number of comorbidities, hospital location (rural vs. urban), region (Northeast, Midwest, West, or South), teaching status, and size. Fisher’s exact test and Student t-test were used to compared proportions and continuous variables, respectively. Results: A total of 119,006 patients underwent inpatient ERCP in 2012, 2010, 2007, 2004, and 2002, 14,772 of whom developed post-ERCP pancreatitis leading to a cumulative incidence of 12.4%. Incidence of post-ERCP pancreatitis by year is shown in Table 1. The mortality rate, ICU transfer rate, and LOS do not show a particular trend over the past decade, and the disease burden ranges from over $7.6 million in 2004 to over $52.7 million in 2010 (Table 1). Conclusions: The incidence of post-ERCP pancreatitis appears to be increasing over the past decade, despite the routine use of NSAIDs and prophylactic pancreatic stent placement. The ICU transfer rate, LOS, and mortality have similarly not improved over this time period. Table 1. Post-ERCP pancreatitis outcome trends between 2002 and

Primary Cesarean Delivery Prevention

INTRODUCTION: Reducing the cesarean delivery rate is a national priority. Obstetrician–gynecologists working in collaboration with certified nurse-midwives demonstrate that a Collaborative Model of Care has the potential to yield the very best obstetric outcomes. This model is based on 1) screening criteria; 2) antepartum guidelines; 3) communication patterns of consultation, collaboration, and referral; 4) evidence-based intrapartum guidelines; 5) innovative labor management strategies; 6) removal of time limits for labor progress; and 7) availability of operative vaginal and breech delivery. METHODS: This is an observational report and data analysis of the first 1,000 deliveries managed by certified nurse-midwives in consultation with obstetrician–gynecologists in a Collaborative Model of Care in an academic medical center from 2010 to 2013. RESULTS: Outcome data from this innovative Collaborative Model of Care show a cesarean delivery rate of 3.6% and a primary cesarean delivery rate of 2.6%. If antepartum transfers at term are included in the analysis, the cesarean delivery rate is 5.6%. The model yields an 88% normal vaginal delivery rate and a 12% epidural rate. The vaginal birth after cesarean delivery success rate is 93%. Vaginal breech birthrate is 75%. The neonatal intensive care unit transfer rate is 5%. CONCLUSIONS: A Collaborative Model of Care between obstetrician–gynecologists and certified nurse-midwives in a university-based setting has the potential to significantly reduce the cesarean delivery rate. Duplication of this model in diverse patient populations will significantly reduce the national cesarean delivery rates, increase rates of normal vaginal delivery, and yield optimal outcomes for our nations' mothers and neonates.

Rapid Response Team Implementation on a Burn Surgery/Acute Care Ward

To date there is limited evidence of efficacy for rapid response teams (RRT) in burns despite widespread their implementation in U.S. hospitals. The burn surgery/acute care ward at the Harborview Medical Center, Seattle, Washington, primarily treats burns, acute wounds, and pediatric trauma patients, but also accepts overflow surgical and medical patients. The authors hypothesize that institutional RRT implementation in 2006 has reduced code blue activations, unplanned intensive care unit (ICU) transfers, and mortality on the acute care ward of this hospital. The authors retrospectively analyzed all patients treated in our acute care unit before (2000-2004) and after RRT implementation (2007-2011). Patient, injury, and treatment outcomes information were collected and analyzed. The authors specifically examined clinical signs that triggered RRT activation and processes of care after activation. They compared code blue activation rates, unplanned ICU transfers, and mortality between the two periods by Poisson regression. The acute care unit treated 7092 patients before and 9357 patients after RRT implementation. There were 409 RRT activations in 329 patients, 18 of whom ultimately died during hospitalization. Those who died had higher rates of stridor (P = .03), tachypnea (P = .001), and low oxygen saturations (P = .02) compared with survivors. Fewer burn and surgical patients died after implementation (seven patients; 22% of all deaths) compared with patients who died pre-RRT (27 patients; 53% of all deaths). After adjustment for case-mix index, age, and medical service differences between the two periods, code blue calls decreased from 1.4/1000 to 0.4/1000 admissions (P = .04), unplanned ICU transfer rates decreased from 65/1000 to 50/1000 admissions (P < .01), and hospital deaths decreased from 4.5/1000 to 3.3/1000 admissions (P = .11). Since its implementation, RRT activation has been frequently used in the acute care ward of this hospital. Respiratory symptoms distinguish RRT patients who die during hospitalization compared with survivors. RRT implementation was associated with fewer code blue activations, unplanned ICU transfers, and a trend toward reduced in-hospital deaths, particularly in burn and surgical patients.

Simple clinical score is associated with mortality and length of stay of acute general medical admissions to an Australian hospital

In a rural Irish hospital, a simple clinical score (SCS) determined at the time of admission enabled stratification of acute general medical admissions into five categories that were associated incrementally with patients' immediate and 30-day mortality. The aim of this study was to examine the representative performance of this SCS in predicting the outcomes of general medical admissions to an Australian teaching hospital. A retrospective chart review was undertaken of a representative sample from 480 admissions in 2007 to an urban university teaching hospital in Australia. The SCS was calculated and related to that patient's outcome in terms of mortality, length of stay, nursing home placement on discharge, the occurrence of medical emergency team call and intensive care unit transfer. These data were compared, where possible, with the outcomes reported in the Irish hospital. Four hundred and seventeen complete sets of data allowed calculation of the SCS. There were significant linear correlations of the SCS (divided into quintiles) and patients' in-hospital and 30-day mortality, their length of stay and their discharge to a nursing home. There was no association of the SCS and the patients' readmission rate, intensive care unit transfer rate or likelihood of a medical emergency team call. The significant trends replicated those from the Irish hospital. The SCS can predict significant outcomes for general medical admissions in an Australian hospital despite obvious differences to the hospital of its derivation. A wider study of Australasian hospitals and the performance of the SCS as a predictor of general medical admission outcomes is underway.

Hospitalist bed management effecting throughput from the emergency department to the intensive care unit

Rationale Emergency department (ED) patients in need of an intensive care unit (ICU) admission are very sick. Reducing the length of time to get these patients into ICU beds is associated with improved outcomes. Objective To reduce the ED length of stay for patients requiring admission to the medical ICU or coronary care unit through the implementation of the “active bed management” (ABM) intervention. Methods A pre-post study design compared data from November 2006 to February 2007 with those from those same months in the prior year at Johns Hopkins Bayview Medical Center in Baltimore. The ABM intervention was carried out by hospitalist physicians and involved: (i) making triage decisions for patients to be admitted and facilitating their transfer from ED to the appropriate care setting and (ii) having proactive management of Department of Medicine resources, which included twice-daily ICU bed management rounds and regular visits to the ED to assess flow. Measurement Throughput time for patients presenting to the ED requiring ICU admission was analyzed. Main Results The ED census was higher during the intervention period as compared with the control period, 17 573 versus 16 148 patients. Throughput from ED to coronary care unit and medical ICU beds was reduced by 99 (±14) minutes (from 353 minutes in the control period to 254 minutes in the 4 months after the initiation of ABM, P < .0001). Staffing, length of stay, case mix index, ICU transfer rates, and ICU death rates were stable across the 2 periods, all P = not significant. Conclusion Conscientious management of hospital beds, in this case by hospitalist physicians providing ABM, can have a positive and substantial impact on the ED throughput of critically ill patients admitted to ICU beds. This efficiency is likely to positively have impacted on patient satisfaction and safety.

Active Bed Management by Hospitalists and Emergency Department Throughput

When emergency departments are overcrowded, ambulances are diverted. Interventions focused primarily on emergency departments have had limited success. To discover whether an active bed management, quality improvement initiative could reduce ambulance diversion hours and emergency department throughput times. Pre-post study that compared institutional data from November 2006 to February 2007 (intervention period) with data from November 2005 to February 2006 (control period). Johns Hopkins Bayview Medical Center, Baltimore, Maryland. All adult patients registered in the emergency department during the study periods. Active bed management is a hospitalist-led, multifaceted intervention that consists of proactive management of hospital and departmental resources, including twice-daily bed management rounds in the intensive care unit and regular visits to the emergency department to assess congestion and flow; assignment of all admissions to the department of medicine and facilitating transfer from the emergency department to the appropriate care setting; and support from the "bed director," who can mobilize additional resources in real time to augment hospital capacity to address emergency department throughput problems. Emergency department throughput times and ambulance diversion hours. The emergency department census was 8.8% higher during the intervention period than in the control period (17 573 patients vs. 16 148 patients). Throughput for patients who were admitted decreased by 98 minutes (SD, 10) (from 458 minutes in the control period to 360 minutes during the intervention period). Throughput for patients who were not admitted did not change (274 minutes vs. 269 minutes). The percentage of hours that the emergency department was on "yellow alert" (ambulance diversion because of emergency department crowding) decreased 6%, and the percentage of hours on "red alert" (ambulance diversion due to lack of intensive care unit beds in the hospital) decreased 27%. Staffing, length of stay, case-mix index, intensive care unit transfer rates, and mortality rates were stable across the 2 periods. Pre-post designs are less effective than randomized, controlled trials on the study design hierarchy, and unidentified external forces may have influenced the results. The study was done at a single hospital, and the findings may not be generalizable to other institutions. Emergency department throughput and diversion status improved with the implementation of an active bed management process coordinated by hospitalists.

Promoting Patient Safety: The Rapid Medical Response Team

Adverse events are estimated to affect up to 17% of hospitalized patients and to cause up to 98,000 patient deaths per year in the United States. Unexpected codes in hospitalized patients are one of the most significant adverse events, carrying a risk of death that is reported to range from 50% to 80%. The Rapid Medical Response Team (RMRT) was an initiative designed to reduce adverse events, specifically failure to rescue, leading to nonintensive care unit (nonICU) codes. This initiative was funded, as part of the Transforming Care at the Bedside (TCAB) program, by a grant from the Robert Wood Johnson Foundation. To determine whether the RMRT had a significant impact on our nonICU code rate, we did a retrospective, noncohort comparison of 2004 (preRMRT) data with 2005 (postRMRT) data. Our main outcome measures were nonICU codes, mortality rate, and unplanned patient transfers to the intensive care unit (ICU). There was a decrease in the nonICU code rate per 1000 discharges from 1.90 in 2004 to 1.01 in 2005. Implementation of the RMRT correlates to a statistically significant decrease in the nonICU code rate (p = .018; relative risk, 0.53 [95% confidence interval, 0.31-0.91]). The nonICU mortality rate remained unchanged at 2.01%. The unplanned ICU transfer rate for 2005 was 47%. Implementation of RMRTs can decrease nonICU code rates and the rate of unplanned ICU transfers. RMRTs can empower staff, enhance expertise and communication skills, and support a culture of safety.

Which children with fever and neutropenia can be safely treated as outpatients?

Which children with fever and neutropenia can be safely treated as outpatients?