Rapid Response Calls Research Articles

IS FRAILTY STATUS A TRIGGER FOR GOALS OF CARE DOCUMENTATION IN OLDER PATIENTS ADMITTED TO THE HOSPITAL?

TYPE: Abstract Publication TOPIC: Critical Care PURPOSE: Goals of care (GOC) are important clinical documents, that should be documented early, to avoid futile or unwarranted interventions in the event of clinical deterioration in frail older patients. It is unclear whether frailty is associated with such documentations. To assess associations between frailty, as measured by Hospital Frailty Risk Score (HFRS), and GOC documentation in newly admitted older patients and outcomes. METHODS: Retrospective single-centre study of patients aged ≥80 years admitted to the study hospital between 1/3/2015 and 31/8/2015. Primary outcome was GOC documentation within 72-hours in frail (HFRS ≥5) and non-frail (HFRS <5) patients. Secondary outcomes included documentation during hospital stay, in-hospital mortality, rapid response calls (RRC), discharge destination, and 28-day readmission rate. RESULTS: 529 (47.3%) of the 1,118 patients were frail. 604 patients (54%) had GOC documented during their hospitalization (60.1% vs. 48.6%; p<0.001); 92.5% of these within 72-hours (53.5% vs. 46.9%; p<0.027; OR 1.05 [1.03–1.08]), commony in frail patients. RRC frequented frail patients (12.5% vs. 5.4%, p<0.001), as was in-hospital mortality (10.8% vs 3.6%, p<0.001, OR 1.08 [1.04–1.13]). Frail patients had longer hospitalisations (median 5.3 vs 2.9 days, p<0.001) and less likely to be discharged to their usual accommodations (32.3% vs 57.7%; p<0.001) than non-frail patients. No difference in 28-days readmission rates (6.6% vs. 8.5%; p=0.238). CONCLUSIONS: Older frail patients were found to be significantly more likely to have timely goals of care documented than older non-frail patients. Frail patients had more RRC, longer hospitalisation and increased hospital mortality. CLINICAL IMPLICATIONS: Just over 50% of older frail patients have goals of care documented Frail patients have worse outcomes DISCLOSURE: No significant relationships. KEYWORDS: Goals of care, Frailty, Hospital frailty risk score

Implementing a Clinical Practice Guideline on Opioid-Induced Advancing Sedation and Respiratory Depression.

Opioid-induced respiratory depression (OIRD) is a serious adverse reaction associated with opioid administration. The purpose of this quality improvement study was to evaluate the impact of implementing a clinical practice guideline for OIRD in a medical-surgical setting lacking standardized monitoring techniques and reporting criteria for patients receiving opioid analgesia. An American Society for Pain Management Nursing protocol was implemented in 4 medical/surgical units. The impact on OIRD-related nurse knowledge, documentation, and opioid-related rapid response calls was measured pre- and postimplementation. Nurse OIRD-related knowledge significantly increased. The number of naloxone administrations associated with prior intravenous opioid analgesic administration did not significantly change. However, there was a significant decrease in the postimplementation number of respiratory distress-related rapid response calls. Implementation of the American Society for Pain Management Nursing guidelines had a positive impact on knowledge, documentation, early intervention of OIRD, and the number of opioid-related rapid response calls.

1047: RAPID RESPONSE CALLS: HAVE WE MET EXPECTATIONS?

Kuruvilla, Alexander1; Venkataraman, Ramesh1; Rajagopal, Senthilkumar2; Ramakrishnan, Nagarajan3 Author Information

Promoting Teamwork for Rapid Response Teams Through Simulation Training.

Use of teamwork skills during rapid response calls is important in the management of patient decompensation outside of the intensive care unit. The ability of a rapid response team (RRT) to influence patient outcomes depends on early team building and effective team performance. Simulation-based team training (SBTT) has been shown to be effective in teaching nontechnical teamwork skills. Rapid Cycle Deliberate Practice (RCDP) is becoming increasingly popular in simulation-based education. Emerging literature on the application of RCDP suggests this method may be superior to traditional reflective debriefing (TRD) in the acquisition of technical skills related to medical management, but fewer data exist that evaluate application of RCDP in teaching nontechnical teamwork skills. We describe a blended approach, using TRD with RCDP to hardwire teamwork behaviors including role assignment, task delegation, situational awareness, global assessment, and shared mental model to a nursing-led RRT. [J Contin Educ Nurs. 2019;50(11):523-528.].

Characteristics of Rapid Response Calls in the United States: An Analysis of the First 402,023 Adult Cases From the Get With the Guidelines Resuscitation-Medical Emergency Team Registry

To characterize the rapid response team activations, and the patients receiving them, in the American Heart Association-sponsored Get With The Guidelines Resuscitation-Medical Emergency Team cohort between 2005 and 2015. Retrospective multicenter cohort study. Three hundred sixty U.S. hospitals. Consecutive adult patients experiencing rapid response team activation. Rapid response team activation. The cohort included 402,023 rapid response team activations from 347,401 unique healthcare encounters. Respiratory triggers (38.0%) and cardiac triggers (37.4%) were most common. The most frequent interventions-pulse oximetry (66.5%), other monitoring (59.6%), and supplemental oxygen (62.0%)-were noninvasive. Fluids were the most common medication ordered (19.3%), but new antibiotic orders were rare (1.2%). More than 10% of rapid response teams resulted in code status changes. Hospital mortality was over 14% and increased with subsequent rapid response activations. Although patients requiring rapid response team activation have high inpatient mortality, most rapid response team activations involve relatively few interventions, which may limit these teams' ability to improve patient outcomes.

Lactate Predicts Both Short- and Long-Term Mortality in Patients With and Without Sepsis.

Objective:To measure the relationship between lactate and mortality in hospital inpatients. Main outcomes of interest were 3-day, 30-day, and 1-year all-cause mortality.Design:Retrospective cohort study, October 2011 to September 2013.Setting:University-affiliated US Veterans Affairs Hospital.Patients:All inpatients with lactate level measured during the study period.Measurements:Analysis of peak lactate level (mmol/L) during the most recent admission for patients who died, and peak lactate level during an admission for surviving patients. Covariates including sepsis, ICU admission, code blue and rapid response calls, medical vs surgical ward, liver disease, kidney disease, and hospice status were recorded.Results:In total, 3325 inpatients were included; 564 patients had sepsis. Median lactate 1.7 mmol/L (interquartile range [IQR] 1.2-2.6). The 3-day, 30-day, and 1-year mortality were 2.5%, 10%, and 24%, respectively. A lactate level cutoff of ⩾4 mmol/L had best test characteristics (sensitivity 52.4%, specificity 91.4%) to predict increased 3-day mortality. Unadjusted risk ratio of death in 3 days for lactate ⩾4 was 10.3 (95% confidence interval [CI] 6.8-15.7). Patients with sepsis had a consistently higher risk of death compared with patients without sepsis for any given level of lactate. Adjusted odds ratio (OR) of 3-day mortality for lactate ⩾4 was 7.6 (95% CI 4.6-12.5); 30-day mortality was 2.6 (95% CI 1.9-3.6); and 1-year mortality was 1.8 (95% CI 1.4-2.6). Lactates in the normal range (<1.7) were also independently associated with 30-day and 1-year mortality.Conclusions:Lactate predicts risk of death in all patients, although patients with sepsis have a higher mortality for any given lactate level. We report the novel finding that serum lactate, including normal values, is associated with long-term mortality.

Assessment of a Targeted Electronic Health Record Intervention to Reduce Telemetry Duration

Physicians frequently use cardiac monitoring, or telemetry, beyond the duration recommended by published practice standards, resulting in "alarm fatigue" and excess cost. Prior studies have demonstrated an association between multicomponent quality improvement interventions and safe reduction of telemetry duration. To determine if a single-component intervention, a targeted electronic health record (EHR) alert, could achieve similar gains to multicomponent interventions and safely reduce unnecessary monitoring. This cluster-randomized clinical trial was conducted between November 2016 and May 2017 on the general medicine service of the Division of Hospital Medicine at the University of California, San Francisco Medical Center and included physicians of 12 inpatient medical teams (6 intervention, 6 control). The EHR alert was randomized to half of the teams on the general medicine service. The alert displayed during daytime hours when physicians attempted to place an order for patients not in the intensive care unit whose telemetry order duration exceeded the recommended duration for a given indication. The primary outcome was telemetry monitoring hours per hospitalization, which was measured using time-stamped orders data from the EHR database. Physician responses to the alert were collected using EHR reporting tools. The potential adverse outcomes of rapid-response calls and medical emergency events were measured by counting the notes documenting these events in the EHR. Of the 1021 patients included in this study, in the intervention arm, there was a mean (SD) age of 64.5 (18.9) and 215 (45%) were women; in the control arm, there was a mean (SD) age of 63.8 (19.1) and 249 (46%) were women. The 12 teams were stratified to 8 house-staff teams and 4 hospitalist teams, with 499 hospitalizations analyzed in the intervention arm and 567 hospitalizations analyzed in the control arm. The alert prompted a significant reduction in telemetry monitoring duration (-8.7 hours per hospitalization; 95% CI, -14.1 to -3.5 hours; P = .001) with no significant change in rapid-response calls or medical emergency events. The most common physician response to the alert was to discontinue telemetry monitoring (62% of 200 alerts). A targeted EHR alert can safely and successfully reduce cardiac monitoring by prompting discontinuation when appropriate. This single-component electronic intervention is less resource intensive than typical multicomponent interventions that include human resources. ClinicalTrials.gov identifier: NCT02529176.

Abstract 264: Use of an Acronym to Reduce Medical Emergency Call Time and Improve Survival

Introduction: An average of 1500 medical emergencies are called to the operators each month for the main campus Cleveland Clinic. Acronyms can help the employee to remember necessary information to quickly and accurately activate the right medical emergency team in a short time. We developed the acronym LEAN (L-Location, E-Event Type; code or rapid response, A-Adult or Child, N-Call back number). We reduced the length of the call which led to the prompt activation of the medical emergency team. Hypothesis: We hypothesized that this quality improvement initiative, using the LEAN acronym would: 1. Reduce length of call time to the operator and 2. Lead to increased event survival of event for patients who have had a life-threatening medical emergency. Methods: The LEAN acronym was implemented in 2016 by sharing this acronym at staff meetings, and daily huddles. We developed an operator scorecard which tracked the average call time to the 111 (code) and 122 (rapid response) operator lines before and after LEAN implementation. We used our AHA Get With The Guidelines-Resuscitation® data to determine cardiopulmonary arrest (CPA) event survival. Results: Since August of 2016 we have reduced our 122 rapid response calls by 30 seconds and our 111 code calls by 12 seconds. CPA survival rates were 73% (437 of 599) in 2015 and 78.9% (548 of 703) in 2017, for an 8.1% increase ( Figure 1 ). While there is not a statistically significant ( p = 0.511) difference between time periods when we look at percentage of lives saved, the number of lives saved increased. This is a clinically important difference because more people survived. We plan to continue to disseminate LEAN and work to improve response time. Conclusion: Since we introduced LEAN there has been a reduction in the time to activation of our medical emergency teams and an 8% increase in our GWTG-R® Cardiopulmonary Arrest event survival. Lives were saved and LEAN may have played a role in this clinically important difference.

Abstract P-430: RISK IS NOT THE SAME AS ACUITY: A FORMALISED SYTEM OF RISK ASSESSMENT, COMMUNICATION AND MANAGEMENT IN A PAEDIATRIC INTENSIVE CARE UNIT.

Aims & Objectives: We aimed to develop a formalised system to reduce variations in how patient risks were identified, communicated and managed. A review of adverse incidents identified occasions when patient supervision was suboptimal in the presence of known risk factors. Methods A multidisciplinary team used adverse incident data and collective clinical expertise to devise the ‘PICU Risk Matrix’. It incorporates six categories: Stability, Technology, High Risk Medications, Patient Behaviour, Physical Environment and Staffing Factors. A ‘safety huddle’ was introduced, where the tool was used to assess, document and handover individual patient risk factors. Consideration of the adequacy of nurses’ skillset for specific risk factors occurs every time the primary nurse is required to leave their patient. Data was collected on factors impacting on nurses’ capacity to supervise patients safely. A staff survey collected information on the impact of the changes on attitudes and practices relating to patient safety. Results Analysis of over 4000 patient risk assessments demonstrated that 78% of patients were classified as either ‘Very High’ or ‘High’ risk. Night shifts were found to be a time of reduced staffing levels with an unpredictable workload complicated by unplanned admissions, rapid response calls and other critical events, as well as coordinating safe meal reliefs. Nurses reported that patient risks are clearly identified, communication about risk has improved, there is greater attention to nursing skill set, and less experienced nurses are felling empowered to identify areas of concern. Conclusions A demonstrated change in practice has occurred. Data collected will improve the planning and organisation of safe patient supervision in PICU.

Association of Standardized Tracheostomy Care Protocol Implementation and Reinforcement With the Prevention of Life-Threatening Respiratory Events

ImportanceMucus plugging after tracheostomy is a preventable cause of respiratory distress. Implementation of standardized tracheostomy care guidelines may reduce the occurrence of fatal respiratory compromise.ObjectiveTo determine the effect of implementing and reinforcing a standardized tracheostomy care protocol on the occurrence of acute life-threatening respiratory events.Design, Setting, and ParticipantsRetrospective cohort study of adult patients who received a tracheostomy between May 2014 and August 2016 at a tertiary care center.Main Outcomes and MeasuresPatient demographics, tracheostomy indication, rapid response for mucus plugging and other acute events, duration of hospital stay, and levels of care that the patients received were recorded through examination of clinical logs. Statistical analysis was conducted between patients before protocol implementation and patients after protocol implementation in terms of rapid-response use, and intragroup comparison of the mean length of stay in various hospital units was also analyzed.ResultsA total of 247 patients (89 women [36%]; mean [SD] age, 58.5 [12.3] years), 117 preprotocol and 130 postprotocol, met inclusion criteria. Of the 130 patients in the postprotocol cohort, 123 (93%) were on the new tracheostomy care protocol. Preprotocol rapid-response rate was 21 of 117 patients (17.9%) and postprotocol response rate was 12 of 130 patients (9.2%) for a difference of 8.7% (95% CI, 0.2%-18.0%). In terms of mucus plugging, preprotocol rate was 8 of 117 patients (6.8%) and the postprotocol rate was 1 of 130 patients (0.8%) for a difference of 6.0% (95% CI, 1.3%-12.2%). Intragroup difference of the mean time spent (days) in various care units between patients in the no rapid-response group vs rapid-response group demonstrated clinically meaningful longer stay for rapid responses in both preprotocol and postprotocol groups for the intensive care unit (preprotocol, 2.03; 95% CI, 1.03-3.03 vs postprotocol, 3.02; 95% CI, 1.49-4.45) and step down units (preprotocol, 1.40; 95% CI, 0.77-2.02 vs postprotocol, 2.11; 95% CI, 0.78 to 3.44).Conclusions and RelevanceImplementation and reinforcement of a standardized tracheostomy care protocol was associated with a reduction in the occurrences of rapid-response calls for life-threatening mucus plugging and is recommended for clinical practice. In addition, length of stay in the intensive care unit and intermediate surgical care unit was increased in a clinically meaningful way for patients who experienced a rapid-response event.

Perioperative Surgical Home Reduces Rapid Response Calls to a Postoperative Surgical Ward: How Anesthesiologists Are Improving the Inpatient Safety Net.

The Perioperative Surgical Home (PSH) is an anesthesiologist-led, coordinated care model that may improve patient experience and safety. We hypothesized that PSH will decrease activation of the rapid response system for surgical inpatients. This retrospective study was performed at an academic Veterans Affairs hospital with a PSH. Data from both medical and surgical cohorts admitted to a single ward were analyzed for the Pre-PSH (July 2006 to October 2010) and Post-PSH (November 2011 to May 2015) epochs. The primary outcome was incidence of rapid response team (RRT) activations per 1000 bed-days. Surgical patients had 5.8 RRT activations per 1000 bed-days Pre-PSH versus 3.7/1000 bed-days Post-PSH ( P = .006). There was no difference in RRT activations per 1000 bed-days for medical patients before and after PSH implementation. Pre-PSH was an independent predictor of mortality in the multivariable model (odds ratio = 1.7; P = .010). PSH is associated with decreased RRT activations among surgical inpatients only.

Post-operative outcomes in older patients: a single-centre observational study.

Improved life-expectancies have seen increased rates of older patients undergoing surgery worldwide. These patients are at increased risk of post-operative complications. Australian evidence is limited regarding the association between age and post-operative outcomes, especially rapid response calls (RRCs) as indicators of adverse outcomes. The aim was to compare the post-operative outcomes of older patients (≥80 years) to younger patients. Specifically, 30-day in-hospital mortality; unplanned intensive care unit (ICU) admission; and RRC activation within 72 h post-operatively. Single-centre retrospective observational study conducted over 12 months in a metropolitan Australian hospital. All adult patients (≥16 years) undergoing surgical procedures were included, excluding cardiac and obstetric/gynaecological surgeries. Patient co-morbidities were quantified using Charlson co-morbidity index (CCI) and American Society of Anesthesiologists physical status classification. Seven thousand four hundred and seventy-nine patients met inclusion criteria, 14.5% (n = 1086) aged ≥80 years. Most procedures (65%) were elective; and general surgical procedures were most common (24.2%). Compared to younger patients, older patients had significantly higher 30-day mortality (2.3% versus 0.2%; P < 0.001), increased post-operative RRC rates (7.3% versus 1.2%; P < 0.001), and unplanned ICU admissions (3.2% versus 1.6%; P < 0.001). Increasing age was associated with increased risk of post-operative RRC, unplanned ICU admission, and in-hospital mortality (all P < 0.01), with associations remaining significant after controlling for surgery type and CCI. Older patients are at increased risk of adverse post-operative outcomes, including post-operative RRC, unplanned ICU admission, and mortality, especially if they underwent emergency procedures. This has implications for preoperative risk stratification and post-operative management. Incidence of post-operative RRCs may be an important indicator of post-operative care.

Timing of palliative care team referrals for inpatients receiving rapid response services: A retrospective pilot study in a US hospital

Background/objectivesResearch indicates up to one-third of rapid response team calls relate to end-of-life symptoms. The CriSTAL criteria were developed as a screening tool to identify high risk of death within three months. The primary purpose of this pilot study was to investigate the timing of palliative care referrals in patients receiving rapid response team services, and patients’ CriSTAL criteria score on admission. The potential feasibility of using the CriSTAL tool to stimulate earlier Palliative Care Team (PCT) referral served as an underlying goal, and investigation of a relationship between specific CriSTAL criteria and the prediction of in-hospital death was a secondary objective. DesignA retrospective chart review of rapid response calls made in 2015 was used to identify patient risk of death on admission based on the CriSTAL criteria. The presence and timing of PCT referral as well as patient survival status to hospital discharge were documented for comparison. Setting/participantsA sample of 183 charts from 584 inpatients involved in over 600 RRT events recorded in 2015. The study was undertaken in a 676-bed teaching hospital in the Midwestern U.S. Methods/resultsNinety-one patients died during the hospital stay while 92 patients from the 493 individuals who survived were randomly selected for full analysis. Applying CriSTAL criteria to the 141 individuals aged 50 years or older indicated that frailty (OR=1.43, 95%CI 1.08–1.89, p=0.012), being a male (OR=3.14; 95%CI 1.40–7.05, p=0.006), and the presence of two or more comorbidities (OR=3.71, 95%CI 1.67–8.24, p=0.001) were the most significant predictors of in-hospital death after adjusting for age. A CriSTAL score of 6 was the optimal cut-off for high-risk of in-hospital death. Palliative care consultations within the high-risk population occurred for 45.2% of the deceased and 40.4% of the survivors. Consultation often occurred within two days of the RRT event and many patients (46.8%) died within one day of the consultation. ConclusionA positive relationship was found between the CriSTAL score, palliative care referral, and in-hospital mortality in patients who received RRT services. The study indicates a need for earlier PCT referral, showcases the potential to identify high risk of in-hospital death upon admission and supports the feasibility of using the CriSTAL criteria tool to encourage earlier PCT referrals.

Implementing an Alcohol Withdrawal Protocol: A Quality Improvement Project.

This quality improvement project evaluates the effectiveness of implementing an evidence-based alcohol withdrawal protocol in an acute care setting. Patient outcomes, length of stay, and nurses' knowledge and satisfaction with care are compared pre- and postimplementation. Implementation resulted in significant reduction of restraint use, transfers to critical care, 1:1 observation, and length of stay, whereas no reduction was seen in rapid response calls. Nurses' knowledge post-alcohol withdrawal protocol education increased and satisfaction with patient care improved.

Physiological and clinical outcomes associated with fluid bolus therapy administered at rapid response calls for hypotension; a retrospective observational study

Physiological and clinical outcomes associated with fluid bolus therapy administered at rapid response calls for hypotension; a retrospective observational study

Implementation of a Pediatric Early Warning Scoring System at an Academic Medical Center.

Despite the addition of family-activated rapid response to the rapid response team algorithm, a children's hospital did not see an increase in utilization of the pediatric rapid response team. A Pediatric Early Warning Score in non-ICU pediatric inpatient units was implemented to increase the number of rapid response team activations. A retrospective review of the 130-bed facility, over a 12-month period, revealed an increase in pediatric rapid response calls, with a subsequent decrease in code team activations. The authors outline implementation strategies and discuss barriers encountered throughout the process, along with implications for nurse leaders.

Rapid Response Team Calls and Unplanned Transfers to the Pediatric Intensive Care Unit in a Pediatric Hospital

Variability in disposition of children according to the time of rapid response calls is unknown. To evaluate times and disposition of rapid response alerts and outcomes for children transferred from acute care to intensive care. Deidentified data on demographics, time and disposition of the child after activation of a rapid response, time of transfer to intensive care, and patient outcomes were reviewed retrospectively. Data for rapid-response patients on time of activation of the response and unplanned transfers to the intensive care unit were compared with data on other patients admitted to the unit. Of 542 rapid responses activated, 321 (59.2%) were called during the daytime. Out of all rapid response activations, 323 children (59.6%) were transferred to intensive care, 164 (30.3%) remained on the general unit, and 19 (3.5%) required resuscitation. More children were transferred to intensive care after rapid response alerts (P = .048) during the daytime (66%) than at night (59%). During the same period, 1313 patients were transferred to intensive care from acute care units. Age, sex, risk of mortality, length of stay, and mortality rate did not differ according to the time of transfer. Mortality among unplanned transfers (3.8%) was significantly higher (P < .001) than among other intensive care patients (1.4%). Only 25% of transfers from acute care units to the intensive care unit occurred after activation of a rapid response team. Most rapid responses were called during daytime hours. Mortality was significantly higher among unplanned transfers from acute care than among other intensive care admissions.

Tracheostomy Complications as a Trigger for an Airway Rapid Response: Analysis and Quality Improvement Considerations.

To analyze the subset of airway rapid response (ARR) calls related to tracheostomy identified over a 46-month period from August 2011 to May 2015 to determine proximate cause, intervention, and outcome and to develop process improvement initiatives. Single-institution multidisciplinary retrospective cohort study. Tertiary care academic medical center in a large urban setting. Hospital inpatients with an in situ tracheostomy or laryngectomy who experienced an ARR. Detailed review of operator, hospital, and patient records related to ARR system activations over a 46-month period. ARR was activated for 28 patients with existing tracheostomy. The cohort included open tracheostomy (n = 14), percutaneous tracheostomy (n = 8), laryngectomy stoma (n = 3), and indeterminate technique (n = 3). The most frequent triggers for emergency airway intervention were decannulation (n = 16), followed by mucus plugging (n = 4). The mean body mass index of ARR patients was higher than that of a comparator tracheostomy cohort (32.9 vs 26.3, P < .001). BMI was >40 in 9 ARR patients. There was 1 mortality in the series. Tracheostomy is a major trigger for ARR with potential fatal outcome. Factors that may contribute to tracheostomy emergencies include high body mass index, surgical technique for open tracheostomy or percutaneous tracheostomy, tracheostomy tube size, and bedside tracheostomy management. Results have triggered a hospital-wide practice improvement plan focused on tracheostomy awareness and documentation, discrete process changes, and implementation of guidelines for emergency management.

Evaluation of Risk Factors Associated with Code Blue or Rapid Response Calls Within 12 hours of Admission to Medical, Surgical, Telemetry, or Floor Beds from the Emergency Department

The emergency department (ED) physician is responsible for stabilizing and identifying the appropriate level of inpatient care for each admitted patient. Patients sent to a non-intensive care unit (ICU) admitted from the ED may require a “code blue” (CB) or “rapid response” (RR) shortly after admission. Patients who experience these events outside of the ICU have a higher morbidity and mortality than those admitted directly to the ICU. Currently, no decision tool exists to assist ED physicians in recognizing patients who may not meet classic criteria of ICU admission but require such upgraded care within 12 hours of admission. We hypothesize there may be vital signs or laboratory values associated with non-ICU patients having a CB or RR called within 12 hours of admission.

Multicenter development, implementation, and patient safety impacts of a simulation-based module to teach handovers to pediatric residents.

Teaching and evaluation of handovers are important requirements of graduate medical education (GME), but well-defined and effective methods have not been clearly established. Case-based computer simulations provide potential methods to teach, evaluate, and practice handovers. Case-based computer simulation modules were developed. In these modules, trainees care for a virtual patient in a time-lapsed session, followed by real-time synthesis and handover of the clinical information to a partner who uses this information to continue caring for the same patient in a simulated night scenario, with an observer tallying included handover components. The process culminates with evaluator feedback and structured handover education. Surveys were used before and after module implementation to allow the interns to rate the quality of handover provided and record rapid responses and transfers to the ICU. Fifty-two pediatric and medicine/pediatric residents from 2 institutions participated in the modules. "Anticipatory guidance" elements of the handover were the most frequently excluded (missing at least 1 component in 77% of module handovers). There were no significant differences in the proportion of nights with rapid response calls (7.24% vs 12.79%, P=.052) or transfers to the ICU (7.76% vs 11.27%, P=.21) before and after module implementation. Case-based, computer-simulation modules are an easily implemented and generalizable mechanism for handover education and assessment. Although significant improvements in patient safety outcomes were not seen as a result of the educational module alone, novel techniques of this nature may supplement handover bundles that have been demonstrated to improve patient safety.