Rapid Response Calls Research Articles

Mitigating Alarm Fatigue and Improving the Bedside Experience by Reducing Nonactionable Alarms

To assess whether conditional bedside alarm triggers can reduce the frequency of non-actionable alarms without compromising patient safety and enhance nursing and family satisfaction. Single center, quality improvement initiative in an acute care cardiac unit (ACCU) and pediatric intensive care unit (PICU). Following the 4-week pre-intervention baseline period, bedside monitors were programmed with hierarchical time delay and conditional alarm triggers. Bedside alarms were tallied for 4 weeks each in the immediate post intervention period and 2-year follow-up. The primary outcome was alarms per monitored patient day. Nurses and families were surveyed pre- and post-intervention. A total of 1509 patients contributed to 2034, 1968, and 2043 monitored patient days which were evaluated in the baseline, follow-up, and 2-year follow-up periods, respectively. The median number of alarms per monitored patient day decreased by 75% in the PICU (p<0.001) and 82% in the ACCU (p<0.001) with sustained effect at 2-year follow-up. No increase of rapid response calls, emergent transfers, or code events occurred in either unit. Nursing surveys reported an improved capacity to respond to alarms and fewer perceived non-actionable alarms. Family surveys, however, did not demonstrate improved sleep quality. Implemented changes to bedside monitor alarms decreased total alarm frequency in both the acute care cardiac unit and pediatric intensive care unit, improving the care provider experience without compromising safety.

Comparative Outcomes for Microvascular Free Flap Monitoring Outside the Intensive Care Unit.

There is a trend towards nonintensive care unit (ICU) or specialty ward management of select patients. Here, we examine postoperative outcomes for patients transferred to a general ward following microvascular free flap (FF) reconstruction of the head and neck. Retrospective quality control study. Single tertiary care center. Consecutive patients who underwent FF of the head and neck before and after a change in protocol from immediate postoperative monitoring in the ICU ("Pre-protocol") to the general ward setting ("Post-protocol"). Outcomes included overall length of stay (LOS), ICU LOS, FF compromise, and postoperative complications. A total of 150 patients were included, 70 in the pre-protocol group and 80 in the post-protocol group. There were no significant differences in age, sex, comorbidities, tumor stage, or type of FF. Mean LOS decreased from 8.18 to 7.68 days (P = .4), and mean ICU LOS decreased significantly from 5.2 to 1.7 days (P < .01). There were no significant differences in postoperative or airway-related complications (P = .6) or FF failure rate (2.9% vs2.6%, P > .9). There was a non-significant increase in ancillary consults in the post-protocol group (45% vs 33%, P = .13) and a significant increase in rapid response team calls, a nurse-driven safety net for abnormal vitals or mental status (19% vs 3%, P = .003). We show the successful implementation of a protocol shifting care of FF patients from the ICU to a general ward postoperatively, suggesting management on the floor with less frequent flap monitoring is safe and conserves ICU beds. Additional teaching and familiarity with these patients may over time reduce the rapid response calls.

Abstract TP50: Ensuring Safe Post-Procedure Throughput for CEA and CAS Patients

Background: A new policy was implemented in November 2021 to reduce the length of post-anesthesia-care-unit (PACU) stay from 6 hours to 4 hours to reduce the nursing care burden and decrease the length of stay, yet how it affected patients’ events after PACU discharge needed close evaluation. Thus, the QI project aimed to retrospectively examine unexpected or safety events of patients who underwent carotid artery stenting or carotid endarterectomy procedures before versus after implementing the new policy. Objective: To compare and examine the rates of unexpected or safety events that occurred before (5/1/2021 - 10/31/2021; PRE) vs. after (2/1/2022 - 7/31/2022; POST) adoption of the new policy. Methods: A determination of IRB review was granted for the retrospective QI project. The unexpected or safety events included patient issues (rapid response calls, STAT calls to service, or bounce back to a higher level of care) and issues with VS or neuro assessment variability. For group comparison, Fisher’s Exact tests were used for dichotomous information, and the Mann-Whitney U tests were performed for continuous data. Results: A total of 145 patients were identified during the study period composing 75 (51.7%) PRE and 70 (48.3%) POST patients. The rates of VS or neuro assessment variability were similar in both groups (PRE: 1.3% vs. POST: 1.3%, p =1.000). Though we saw a lower rate of patient issues within 24 hours on the floor in POST (4.3%), the difference was not statistically significant (PRE: 8.0%, p =0.496). Conclusion: Inefficient patient throughput can impact currently strained hospital resources. Findings of the QI project confirmed that the new policy did not incur a higher rate of instability on the nursing unit. This data lends confidence to Vascular Surgery and Stroke programs as they seek to streamline patient care and manage hospital resources.

Abstract 325: Two-Year Outcomes of an Electronic Health Record Integrated Rapid Response Team Model

Background: Literature supports improved patient outcomes with dedicated resources for rapid response to patient deterioration in inpatient settings. However, studies of the association of centralized resource allocation and electronic health record (EHR) integration on patient outcomes are lacking. Aim: To improve early, centralized rapid response to patient deterioration and reduce unanticipated transfers to the ICU. Methods: Using a prospective longitudinal quality improvement design, we implemented a centralized, EHR supported patient response team (PRT) at an academic medical center in the southeastern United States. The model served 1,043 inpatient beds. Pre-intervention the PRT used episodic data capture and included 1 critical care RN, 1 physician, and 1 respiratory therapist; each expected to leave assigned patients to respond to non-ICU events. We implemented a dedicated PRT (4 critical care RNs and 1 hospitalist) to provide 24/7 response to code blue, RRT, and stroke code events. The team provided proactive rounding, preventive consultation, and assessment of patients from ICU or emergency within 24 hours. Standardized workflow and outcome documentation was integrated in the EHR. Improvement in processes and outcomes were analyzed using statistical process control charts with 25 data points over a 2-year period. Results: At baseline (FY 2020), the PRT responded to 1739 rapid response calls and 166 code blue events. Unanticipated transfer to ICU occurred in 935 (53.8%) patients. Post-implementation of the integrated PRT model, the rate of early rapid response calls improved (FY 2021 n=2099; FY 2022 n=2239), code blue events decreased (FY 2021 n=151; FY 2022 n=115), and unanticipated ICU transfers also decreased (25%; Figure 1). Conclusions: A centralized PRT model using technology-supported EHR integration, pre-defined workflows, and a dedicated team can reduce non-ICU cardiac arrests and decrease unanticipated transfers to ICU.

The ACCELERATE Plus (assessment and communication excellence for safe patient outcomes) Trial Protocol: a stepped-wedge cluster randomised trial, cost-benefit analysis, and process evaluation

BackgroundNurses play an essential role in patient safety. Inadequate nursing physical assessment and communication in handover practices are associated with increased patient deterioration, falls and pressure injuries. Despite internationally implemented rapid response systems, falls and pressure injury reduction strategies, and recommendations to conduct clinical handovers at patients’ bedside, adverse events persist. This trial aims to evaluate the effectiveness, implementation, and cost–benefit of an externally facilitated, nurse-led intervention delivered at the ward level for core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication. We hypothesise the trial will reduce medical emergency team calls, unplanned intensive care unit admissions, falls and pressure injuries.MethodsA stepped-wedge cluster randomised trial will be conducted over 52 weeks. The intervention consists of a nursing core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication and will be implemented in 24 wards across eight hospitals. The intervention will use theoretically informed implementation strategies for changing clinician behaviour, consisting of: nursing executive site engagement; a train-the-trainer model for cascading facilitation; embedded site leads; nursing unit manager leadership training; nursing and medical ward-level clinical champions; ward nurses’ education workshops; intervention tailoring; and reminders. The primary outcome will be a composite measure of medical emergency team calls (rapid response calls and ‘Code Blue’ calls), unplanned intensive care unit admissions, in-hospital falls and hospital-acquired pressure injuries; these measures individually will also form secondary outcomes. Other secondary outcomes are: i) patient-reported experience measures of receiving safe and patient-centred care, ii) nurses’ perceptions of barriers to physical assessment, readiness to change, and staff engagement, and iii) nurses’ and medical officers’ perceptions of safety culture and interprofessional collaboration. Primary outcome data will be collected for the trial duration, and secondary outcome surveys will be collected prior to each step and at trial conclusion. A cost–benefit analysis and post-trial process evaluation will also be undertaken.DiscussionIf effective, this intervention has the potential to improve nursing care, reduce patient harm and improve patient outcomes. The evidence-based implementation strategy has been designed to be embedded within existing hospital workforces; if cost-effective, it will be readily translatable to other hospitals nationally.Trial registrationAustralian New Zealand Clinical Trials Registry ID: ACTRN12622000155796. Date registered: 31/01/2022.

Implementation of AIRVO™ System for Postoperative Tracheostomy Care in Head and Neck Free Flaps.

Effective postoperative tracheostomy management after free flap surgery is critical but can offer challenges including difficulty with humidification delivery and contraindications toward neck instrumentation. The purpose of this project was to establish a multidisciplinary team and implement the AIRVO™ tracheostomy humidification system for those undergoing free flap surgery and determine its effect on respiratory secretions and related events. A retrospective cohort study of head and neck free flap surgery patients prior to implementation of AIRVO™ (Jan 2021-May 2021) and after (August 2021-December 2021) were analyzed with a 2 month (June 2021-July 2021) implementation phase. Main variables analyzed included excessive tracheal secretions, necessity of supplemental oxygen above baseline for a day or greater, respiratory rapid response calls, elevation to intensive care units (ICU), and length of hospital stay. A total of 82 patients (40 pre-AIRVO™ and 42 with AIRVO™) met criteria for the study. A significant reduction in excessive tracheal secretions (40% pre-AIRVO™, 11.9% with AIRVO™, P = .01) and necessity of supplemental oxygen above baseline (25% pre-AIRVO™, 7.1% with AIRVO™, P = .04) were observed. No significant difference in hospital length of stay (P = .63) was observed. No respiratory rapid responses or elevation to ICU care were seen in either groups. The AIRVO™ system provided an efficient, portable, free of neck instrumentation, and easy to use device that resulted in a reduction in excessive tracheal secretion events and necessity of supplemental oxygenation needs in free flap tracheostomy patients.

A Rapid Response Team (RRT) System at a Cancer Center: Innovative Approaches to System Organization and Clinical RRT Pathways.

The Rapid Response Team (RRT) system at Memorial Sloan Kettering Cancer Center led by critical care medicine (CCM) advanced practice providers (APPs) expanded exponentially between 2009 and 2021. CCM-APPs are trained for care of critically ill patients as well as to oversee rapid response calls. The RRT is composed of a CCM-based RRT-APP, respiratory therapist, RRT-RN, and nursing supervisor. Since program inception, 11 RRT pathways and interventions have been developed and adjusted to improve multidisciplinary patient management. Pathways vary in complexity and require multidisciplinary collaboration. In some circumstances, the RRT patient may require transfer to outside facilities for services not provided at our oncology-based facility. RRT data are tracked across the hospital continuum with on-line reporting through RRT website dashboards. 2021 RRT data on electronic sepsis alerts, behavioral RRT and stroke alerts are presented. The RRT program is monitored through robust quality assurance. The APP-led RRT system's scope of care has been continuously expanded through the creation of RRT pathways to meet the increasingly complex medical needs of our patients.

Impact of Dual Intensive Care Unit and Rapid Response Team Nursing Roles on Service Delivery in the Intensive Care Unit.

Rapid response teams generally consist of multidisciplinary specialist staff members with advanced knowledge and skills to manage deteriorating patients outside of the intensive care unit. These teams consist predominantly of intensive care unit nurses, who often undertake intensive care unit and rapid response team duties concurrently. Little has been published on the impact of these nurses' absence while attending a rapid response call on the nursing workforce, patient care, and resource allocation in the intensive care unit. To explore the impact of nurses' absence due to attending rapid response calls in other areas of the hospital on service delivery and resource allocation in the intensive care unit. A comprehensive search of 3 databases was performed to identify studies on relationships among the rapid response team, the intensive care unit, and nursing staff. The search yielded 6 quantitative studies, 2 qualitative studies, and a mixed-methods study that were included for analysis. Four key themes were identified: (1) workforce, staffing processes, and resource allocation; (2) alterations to workload and resource allocation; (3) adverse events or incidents; and (4) funding variability of rapid response team models. Review of the studies indicated that dual intensive care unit and rapid response team nursing roles have negative effects on nurses' workload, increase the risk of adverse events, and may compromise patient safety. The staffing of both the intensive care unit and the rapid response team should be examined carefully with an eye toward sustainability, cost-effectiveness, and clear outcome measures.

Perioperative outcomes of patients with restless legs syndrome: a single-center retrospective review.

There are multiple stressors in the perioperative period for patients with restless legs syndrome (RLS) that may be implicated in the worsening of symptoms. Our primary objective was to compare the perioperative course of patients with RLS to patients without the diagnosis. This was a single-center, matched-cohort, retrospective chart review of patients with RLS undergoing inpatient procedures from 2015-2019 matched 1:1 with patients without the diagnosis. Patients with RLS had a higher comorbidity burden; specifically, pulmonary, renal, diabetes mellitus, and congestive heart failure. The perioperative course was notable for higher maximum pain scores for patients with RLS in the postanesthesia care unit (odds ratio, 1.29; 95% confidence interval, 1.19-1.40; P < .001). Postoperative patients with RLS also had higher maximum pain scores on postoperative days 0, 1, and 2. The odds of rapid-response calls were higher in patients with RLS (odds ratio, 1.43; 95% confidence interval, 1.18-1.73; P < .001). There were no other significant differences in postoperative complications. The odds of using RLS-triggering medications were lower in the RLS group (odds ratio, 0.85; 95% confidence interval, 0.78-0.92; P < .001). Our single-center retrospective review found that patients with RLS had higher pain scores in the postanesthesia care unit and on the first few postoperative days. Rapid-response team calls were more common in patients with RLS. RLS-triggering medications were significantly less likely to be used in patients with RLS. There were no significant differences in other postoperative events. Gali B, Silber MH, Hanson AC, Portner E, Gay P. Perioperative outcomes of patients with restless legs syndrome: a single-center retrospective review. J Clin Sleep Med. 2022:18(7):1841-1846.

Frailty status, timely goals of care documentation and clinical outcomes in older hospitalised medical patients.

Hospitalised frail older patients are at risk of clinical deterioration. Early goals of care (GOC) documentation is vital to avoid futile/unwarranted interventions in the event of deterioration. To investigate the impact of frailty on timely GOC and its association with clinical outcomes in hospitalised older patients. This was a single-centre retrospective study of all medical patients aged ≥80 years admitted to the acute medical unit between 1/3/2015 and 31/8/2015, with GOC derived from electronic records. Frailty was measured using the Hospital Frailty Risk Score (HFRS) derived from hospital coding data. Primary outcome compared proportions of timely GOC within 72-h between frail (HFRS ≥ 5) and non-frail (HFRS < 5) patients. Exploratory secondary outcomes included in-hospital mortality, rapid response calls (RRC), prolonged length of stay (LOS) and 28-day readmission rates. Of the 1118 admitted patients, 529 (47.3%) were frail. Timely GOC occurred in 50% (559/1118), more commonly in frail patients (283/529, 53.5%) than non-frail patients (276/589, 46.9%), P = 0.027. Frailty was positively associated with timely GOC independent of age and gender (odds ratio=1.28; 95% confidence interval=1.01-163; P = 0.041). In univariable analyses, timely GOC was associated with greater in-hospital mortality, RRC, and hospital LOS in both frail and non-frail patients (all P < 0.05) and greater 28-day readmissions only among frail patients (P = 0.028). Multivariable regression demonstrated that timely GOC was associated only with in-hospital mortality in both frail and non-frail patients, independent of age and gender. Older frail hospitalised patients were more likely to have timely GOC than older non-frail patients. Timely GOC in such patients may avoid burdensome treatments.

Risk perception and emotional wellbeing in healthcare workers involved in rapid response calls during the COVID-19 pandemic: A substudy of a cross-sectional survey

BackgroundCoronavirus disease-2019 (COVID-19) has effected major changes to healthcare delivery within acute care settings. Rapid response calls (RRCs) in healthcare organisations have been effective at identifying and urgently managing acute clinical deterioration. Code-95 RRC were introduced to prewarn healthcare workers (HCWs) attending to patients suspected or confirmed with COVID-19 infection. AimsThe primary aim of the study was to identify the personal impact of the COVID-19 pandemic on HCWs involved in attending Code-95 RRC. We sought to evaluate their perception of risks and effects on wellbeing and identify potential opportunities for improvement at organisational levels. MethodsWe undertook a detailed survey on HCWs attending Code-95 RRCs, including questions that sought to understand the impact of the pandemic as well as their perception of infection risk and emotional wellbeing. This was a substudy of the prospective cross-sectional single-centre survey of HCWs that was conducted over a 3-week period at Frankston Hospital, Victoria, Australia. We adopted a quantitative content analysis approach for free-text responses in this secondary analysis. ResultsFour hundred two free-text comments were received from 297 respondents and were analysed. More than two-thirds (68%, 223/297) were female. Of all comments, 39% (155/402) were related to organisational issues including communication, confusion due to constantly changing infection control policies, and insufficient training. Thirty-three percent of comments (133/402) raised issues regarding the adequacy of personal protective equipment. Anxiety was reported in 25% of comments (101/402) with concerns predominantly relating to emotional stress and fatigue, risks of virus exposure and transmitting the infection to others, and COVID-19 precautions impairing care delivery. Conclusion(s)Our study raises important issues that have relevance for all healthcare organisations in the management of patients with COVID-19. These include the importance of improving communication, especially when infection control policies are revised, optimising training, maintaining adequate personal protective equipment, and HCW support. Early recognition and management of these issues are crucial to maintain optimal healthcare delivery.

Duration and management of sepsis-associated hypotension at rapid response team call-outs to patients subsequently admitted to the intensive care unit: A case series

BackgroundSepsis-related hypotension in hospital patients is a common reason for rapid response team (RRT) attendance and transfer to intensive care, but little is known about the duration and management of hypotension during these RRT call-outs. ObjectivesWe aimed to describe the duration and management of hypotension during RRT call-outs to patients with sepsis-related hypotension who required transfer to intensive care. MethodsRRT call-outs during 2018 for hypotension with transfer to intensive care were identified from a prospectively maintained database of RRT call-outs at a single tertiary hospital. From these, the records of a random sample of 60 cases were reviewed, and those attributed to sepsis and without missing data were described. Hypotension was defined as systolic blood pressure < 90 mmHg. ResultsThere were 117 RRT call-outs for hypotension with transfer to intensive care, and of the 60 cases randomly chosen for further review, 41 were deemed sepsis related and were not missing data. The average age of the patients was 62 years, and 18 (44%) were already receiving antibiotics. The median time to arrival in the intensive care unit was 47 minutes. Patients were hypotensive for approximately two-thirds of their RRT time, despite 88% receiving some initial resuscitative treatments (fluids and/or vasopressors). Thirty-two (78%) were treated with intravenous fluids, and 20 (49%), with vasopressors. Patients spent 3 [2-4] days in intensive care, and 7 (17%) died in hospital. ConclusionsPatients with sepsis-related hypotension requiring an RRT call and transfer to intensive care remain hypotensive for a substantial duration of the call. This concept of adequacy of resuscitation after rapid response calls needs further exploration in a larger study.

COVID-19: Perspectives From Frontline Critical Care Nurses in New York.

New York City quickly became the epicenter of coronavirus disease-2019 (COVID-19) in early March of 2020. While hospitals were aware of the potential of COVID-19, the volume of critically ill patients that flooded the hospitals in the New York City area was clearly not anticipated. Hospital staff worked quickly to create COVID-19-free areas, but were overcome with the volume of COVID-positive critically ill patients. Many newly admitted patients required respiratory support with mechanical ventilation. As Governor Cuomo issued executive orders to stay at home in mid-March, some patients were afraid to go into hospitals despite symptoms of respiratory distress. Once these patients came to the hospital, they were often critically ill. Emergency departments and intensive care units filled rapidly, overwhelming staff and equipment needs with such things as pumps, dialysis machines, medications, and personal protective equipment. Plans for the day were disrupted with frequent rapid response calls and the need for additional beds. Key issues that confronted the COVID-19 response in critical care units at NYU Langone Health included communication, patient and staff safety.

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

BackgroundTo allow better allocation of staff and resources, rapid response teams attending to acutely deteriorating or aggressive patients with suspected or confirmed COVID‐19 infection were pre‐warned with the announcement of 'Code‐95' with calls.AimTo assess healthcare worker (HCW) perspectives on pre‐warning rapid response calls (RRC) with ‘Code‐95’ in announcements when attending to deteriorating or aggressive patients with suspected/confirmed COVID‐19 infection.MethodsDesign: prospective cross‐sectional single‐centre survey of HCW over a 3‐week period. Setting: tertiary public hospital. Participants: HCW caring for deteriorating or aggressive patients. Main outcome measures: the primary outcome was to assess HCW perspectives in attending Code‐95 calls. Secondary outcomes were to identify any differences related to craft group, age, experience or presence of comorbidities.ResultsA total of 297 responses was analysed; 86.7% of HCW (n = 257) attending Code‐95 calls reported anxiety. Medical staff reported greater anxiety in comparison to nursing staff (93.8% vs 78.5%; P = 0.002). Efferent team reported higher anxiety in contrast to afferent team (92.6% vs 58.8%; P = 0.021). There was no significant difference in perceived anxiety based on age (≤40 vs >40 years of age), years of experience (≤5 vs >5 years), comorbidities or mental illness; 54% reported concerns about adequacy of infection‐control policies and personal protective equipment; 45% were worried about inadequate training for responding to Code‐95 calls.ConclusionsMost surveyed HCW supported Code‐95 announcements pre‐warning them of potential COVID‐19 exposure when attending a RRC. However, the majority of HCW reported anxiety when attending these calls. Medical and efferent team HCW perceived greater anxiety compared to nursing and afferent team HCW. The Code‐95 system to pre‐warn rapid response teams may be a useful addition to protecting HCW from infectious diseases, although broader implementation will require greater resourcing, training and support.

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

The NSW Clinical Excellence commission introduced the 'Between the Flags' programme, in response to the death of a young patient, as a system-wide approach for early detection and management of the deteriorating patient in all NSW hospitals. The impact of BTF implementation on the 35 larger hospitals with intensive care units (ICU) has not been reported previously. To assess the impact of 'Between the Flags' (BTF), a two-tier rapid response system across 35 hospitals with an ICU in NSW, on the incidence of in-hospital cardiac arrests and the incidence and outcome of patients admitted to an ICU following cardiac arrest and rapid response team activation. This is a prospective observational study of the BTF registry (August 2010 to June 2016) and the Australian and New Zealand Intensive Care Society Adult Patient Database (January 2008 to December 2016) in 35 New South Wales public hospitals with an ICU. The primary outcome studied was the proportion of in-hospital cardiac arrests. Secondary outcomes included changes in the severity of illness and outcomes of cardiac arrest admissions to the ICU and changes in the volume of rapid response calls. The cardiac arrest rate per 1000 hospital admissions declined from 0.91 in the implementation period to 0.70. Propensity score analysis showed significant declines in ICU and hospital mortality and length of stay for cardiac arrest patients admitted to the ICU (all P < 0.001). The BTF programme was associated with a significant reduction in cardiac arrests in hospitals and ICU admissions secondary to cardiac arrests in 35 NSW hospitals with an ICU.

Rapid response calls in inpatient psychiatric units.

To assess the rates of serious medical issues on psychiatry wards by determining the rate, indication and outcomes of rapid response calls. Using retrospective file review, information regarding rapid response calls during an 8-month period was analysed. Seventy-two rapid response calls were recorded; 7.5% of the admissions involved a rapid response call. Of patients who required a rapid response call, 88.6% had medical comorbidities. Also, 29.2% of rapid response calls required transfer to another ward. Patients on psychiatry wards frequently require urgent medical intervention. Improved collaboration and service planning between general medical and psychiatric service is required to improve clinical care and outcomes for this high-risk group.

Reduction of in-hospital cardiac arrest with sequential deployment of rapid response team and medical emergency team to the emergency department and acute care wards.

PurposeThis study aimed to determine if sequential deployment of a nurse-led Rapid Response Team (RRT) and an intensivist-led Medical Emergency Team (MET) for critically ill patients in the Emergency Department (ED) and acute care wards improved hospital-wide cardiac arrest rates.MethodsIn this single-center, retrospective observational cohort study, we compared the cardiac arrest rates per 1000 patient-days during two time periods. Our hospital instituted a nurse-led RRT in 2012 and added an intensivist-led MET in 2014. We compared the cardiac arrest rates during the nurse-led RRT period and the combined RRT-MET period. With the sequential approach, nurse-led RRT evaluated and managed rapid response calls in acute care wards and if required escalated care and co-managed with an intensivist-led MET. We specifically compared the rates of pulseless electrical activity (PEA) in the two periods. We also looked at the cardiac arrest rates in the ED as RRT-MET co-managed patients with the ED team.ResultsHospital-wide cardiac arrests decreased from 2.2 events per 1000 patient-days in the nurse-led RRT period to 0.8 events per 1000 patient-days in the combined RRT and MET period (p-value = 0.001). Hospital-wide PEA arrests and shockable rhythms both decreased significantly. PEA rhythms significantly decreased in acute care wards and the ED.ConclusionImplementing an intensivist-led MET-RRT significantly decreased the overall cardiac arrest rate relative to the rate under a nurse-led RRT model. Additional MET capabilities and early initiation of advanced, time-sensitive therapies likely had the most impact.

Comparative effectiveness of direct admission and admission through emergency departments for children: a randomized stepped wedge study protocol

BackgroundApproximately 2 million children are hospitalized each year in the United States, with more than three-quarters of non-elective hospitalizations admitted through emergency departments (EDs). Direct admission, defined as admission to hospital without first receiving care in the hospital’s ED, may offer benefits for patients and healthcare systems in quality, timeliness, and experience of care. While ED utilization patterns are well studied, there is a paucity of research comparing the effectiveness of direct and ED admissions. The overall aim of this project is to compare the effectiveness of a standardized direct admission approach to admission beginning in the ED for hospitalized children.Methods/designWe will conduct a stepped wedge cluster randomized controlled trial at 3 structurally and geographically diverse hospitals. A total of 70 primary and urgent care practice sites in the hospitals’ catchment areas will be randomized to a time point when they will begin participation in the multi-stakeholder informed direct admission program. This crossover will be unidirectional and occur at 4 time points, 6 months apart, over a 24-month implementation period. Our primary outcome will be the timeliness of clinical care provision. Secondary outcomes include (i) parent-reported experience of care, (ii) unanticipated transfer to the intensive care unit within 6 h of hospital admission, and (iii) rapid response calls within 6 h of hospital admission. We anticipate that 190 children and adolescents will be directly admitted, with 1506 admitted through EDs.Analyses will compare the effectiveness of direct admission to admission through the ED and will evaluate the causal effect of implementing a direct admission program using linear regression with random effects for referring practice clusters and time period fixed effects. We will further examine the heterogeneity of treatment effects based on hypotheses specified a priori. In addition, we will conduct a mixed-methods process evaluation to assess reach, effectiveness, adoption, implementation, and maintenance of our direct admission intervention.DiscussionOur study represents the first randomized controlled trial to compare the effectiveness of direct admission to admission through the ED for pediatric patients. Our scientific approach, pairing a stepped wedge design with a multi-level assessment of barriers to and facilitators of implementation, will generate valuable data about how positive findings can be reproduced across other healthcare systems.Trial registrationClinicalTrials.gov NCT04192799. Registered on December 10, 2019).

The use of altered rapid response calling criteria in a tertiary referral facility

PurposeThe purpose of this study was to examine the current utilisation of altered rapid response calling criteria (ARRCCs) at a tertiary hospital. MethodsA retrospective review of all acute care admissions across 17 months was undertaken using the hospital administration system and electronic medical record to identify patients with ARRCCs. In patients with altered criteria, the type of alteration, frequency of rapid response calls, cardiac arrest, intensive care admission, and death in the hospital were identified. Comparisons were made using standard statistical methods. ResultsThe total hospital admissions numbered 45 912, with ARRCCs used in 768 (1.7%). Patients with an ARRCC during hospital admission were older (68.5 [55.5, 79.0] vs 59.0 [43.0, 72.0] years, p < 0.001) and had a significantly longer length of hospital stay (6.9 [3.0, 16.3] vs 2 [1, 5] days, p < 0.001).Compared with the total group of patient admissions, patients with ARRCCs more frequently triggered a rapid response team (9.0% vs 14.2%, χ2(1, n = 46 680) = 23.87, p < 0.001), more frequently suffered a cardiac arrest (0.2 vs 0.9%, χ2(1, n = 46 678) = 20.34, p < 0.001), more frequently died in the hospital (p < 0.001), and were less frequently discharged home (χ2(1, n = 46 680) = 43.91, p < 0.001). ConclusionPatients with an ARRCC stayed longer in the hospital and were at increased risk of cardiac arrest and death during hospitalisation. Further exploration of the role of ARRCCs in facilitating individualised care to meet the needs and treatment goals of each patient in the acute hospital setting is required.

Responding to COVID-19 requires strong epidemiological evidence of environmental and societal determining factors

Responding to COVID-19 requires strong epidemiological evidence of environmental and societal determining factors