Rapid Response Team Activation Research Articles

Abstract Su303: Afferent Rapid Response Limb Failure Prior to Non-ICU In-Hospital Cardiac Arrest and Associated In-Hospital Mortality

Introduction/Background: Rapid Response Teams (RRT) have been widely implemented to recognize and manage clinical deterioration outside of the intensive care unit (ICU). Hospital systems frequently rely on individual healthcare provider’s skill and attention to identify early deterioration and activate the appropriate clinical resources. This is referred to as the afferent limb, or triggering mechanism, of the Rapid Response system. Hypothesis: Afferent limb failure leads to delayed clinical intervention and potentially worse outcomes for patients that progress to in-hospital cardiac arrest (IHCA). Goals/Aims: The aim of this retrospective study was to identify if afferent limb failure, defined as failure to recognize two or more standardized early warning criteria in the 24 hours prior to non-ICU IHCA, is associated with increased in-hospital mortality when compared to patients with zero to one standardized early warning criteria. Methods: Non-ICU IHCAs over a 6-year period (January 1 st , 2018, to December 31 st , 2023) at a large academic medical center were reviewed using standardized criteria to determine 1) if any RRT activation criteria had been met in the 24 hours prior to non-ICU IHCA, 2) how many RRT criteria were met, 3) whether an RRT activation occurred, and 4) in-hospital mortality. Statistical analysis included a Chi-Square analysis and Pearson Correlation Coefficient. Results: We identified 386 adult non-ICU IHCAs, with 214 (55.4%) meeting at least two RRT criteria in the 24 hours preceding their non-ICU IHCA. In patients without a preceding RRT activation (N=313), there was significantly higher in-hospital mortality in patients who met two or more RRT criteria prior to their non-ICU IHCA than patients who met one or zero criteria (91/151, 60.2% vs 114/162, 70.3%, p < 0.05). We also found a weak but statistically significant correlation between the total number of RRT criteria met prior to IHCA and in-hospital mortality (r=0.1331, p < 0.05). Conclusion: Afferent limb failure is associated with higher in-hospital mortality in patients with multiple markers of clinical deterioration prior to non-ICU IHCA. There is also an association between in-hospital mortality and the total number of clinical deterioration criteria met prior to non-ICU IHCA.

Pediatric Early Warning Scores Before Rapid Response Poorly Predict Intensive Care Unit Transfers.

The Pediatric Early Warning Score (PEWS) is a clinical tool used to identify children at risk for clinical deterioration, but its utility remains debated, particularly in high-resource settings. Our objective with this study was to assess the predictive performance of the PEWS for unplanned PICU transfers after pediatric rapid response team (RRT) activation. A retrospective cohort study at a tertiary care academic children's hospital included all hospitalized patients up to 21 years old who had RRT activations between August 2021 and July 2022. Demographic and clinical data, the primary reason for RRT activation, and the modified Brighton PEWS were collected. The primary outcome was PICU transfer following RRT activation, and the secondary outcome was rapid escalation of care within 4 hours after RRT activation. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were calculated at multiple PEWS thresholds. Of 297 RRT activations in 244 patients, 183 (63%) resulted in a PICU transfer, 75% of which were due to respiratory concerns. The PEWS was recorded in 89% of RRT activations within the preceding 4 hours. There was no significant difference in the PEWS between patients with or without PICU transfer or rapid escalation of care. The sensitivity, specificity, and AUROC of PEWS for predicting PICU transfer or rapid escalation of care were low (AUROC 0.495-0.613). PEWS within 4 hours before RRT activation was a poor predictor of PICU transfer or rapid escalation care. Further work is needed to develop a more sensitive and specific tool.

Characteristics and outcomes of patients screened by the rapid response team and transferred to intensive care unit in South Korea

The rapid response system (RRS) is associated with a reduction in in-hospital mortality. This study aimed to determine the characteristics and outcomes of patients transferred to the intensive care unit (ICU) by a rapid response team (RRT). This retrospective, multicenter cohort study included patients from nine hospitals in South Korea. Adult patients who were admitted to the general ward (GW) and required RRS activation were included. Patients with do-not-resuscitate orders and without lactate level or Sequential Organ Failure Assessment score were excluded. A total of 8228 patients were enrolled, 3379 were transferred to the ICU. The most common reasons for RRT activation were respiratory distress, sepsis and septic shock. The number of patients who underwent interventions, the length of hospital stays, 28-day mortality, and in-hospital mortality were higher in the ICU group than in the GW group. Factors that could affect both 28-day and in-hospital mortality included the severity score, low PaO2/FiO2 ratio, higher lactate and C-reactive protein levels, and hospitalization time prior to RRT activation. Patients admitted to the ICU after RRT activation generally face more challenging clinical situations, which may affect their survival outcomes.

Use of a continuous single lead electrocardiogram analytic to predict patient deterioration requiring rapid response team activation.

Identifying the onset of patient deterioration is challenging despite the potential to respond to patients earlier with better vital sign monitoring and rapid response team (RRT) activation. In this study an ECG based software as a medical device, the Analytic for Hemodynamic Instability Predictive Index (AHI-PI), was compared to the vital signs of heart rate, blood pressure, and respiratory rate, evaluating how early it indicated risk before an RRT activation. A higher proportion of the events had risk indication by AHI-PI (92.71%) than by vital signs (41.67%). AHI-PI indicated risk early, with an average of over a day before RRT events. In events whose risks were indicated by both AHI-PI and vital signs, AHI-PI demonstrated earlier recognition of deterioration compared to vital signs. A case-control study showed that situations requiring RRTs were more likely to have AHI-PI risk indication than those that did not. The study derived several insights in support of AHI-PI's efficacy as a clinical decision support system. The findings demonstrated AHI-PI's potential to serve as a reliable predictor of future RRT events. It could potentially help clinicians recognize early clinical deterioration and respond to those unnoticed by vital signs, thereby helping clinicians improve clinical outcomes.

Characteristics of Rapid Response Team Calls in a Tertiary Hospital in Egypt

Abstract Background Rapid Response Teams (RRTs) help in the early recognition of deteriorating patients in hospital wards, and provide the needed management at the bedside by a qualified team. Aim of the Work To describe the characteristics of the RRT calls in a tertiary hospital in Egypt. Patients and Methods A prospective cohort study for a one-year duration from January 2021 till December, 2021was conducted, during this period a total of 2338 patients were reviewed, and 34 RRT calls were recorded. Results Our results showed that 10 calls (63%) of Rapid Response Team calls were in the daytime, and Nurses were the main activators with 27 activations (90%). Modified Early Warning scoring system (MEWS) and Pediatric Early Warning Score (PEWS) used were the main cause of RRT activation with a total of (66.7%), the majority of cases didn’t refer to the Intensive Care Unit (ICU), 19 patients stay in the ward (76%) and 22 cases (100%) were recovered. Conclusion More than half of RRT calls were in the daytime, and nurses were the main activators. Most rapid response team activations involve relatively few interventions, patient-activated RRT should consider as a patient right in the future, and further studies showed be conducted to evaluate the best effective methods for applying RRT among different health care facilities.

The impact of frailty and rapid response team activation on patients admitted to the intensive care unit: A case-control matched, observational, single-centre cohort study.

Frailty is a multi-dimensional syndrome associated with mortality and adverse outcomes in patients admitted to the intensive care unit (ICU). Further investigation is warranted to explore the interplay among factors such as frailty, clinical deterioration triggering a medical emergency team (MET) review, and outcomes following admission to the ICU. Single-centre, retrospective observational case-control study of adult patients (>18 years) admitted to a medical-surgical ICU with (cases) or without (controls) a preceding MET review between 4 h and 14 days prior. Matching was performed for age, ICU admission diagnosis, Acute Physiology and Chronic Health Evaluation III (APACHE III) score and the 8-point Clinical Frailty Scale (CFS). Cox proportional hazard regression modelling was performed to determine associations with 30-day mortality after admission to ICU. A total of 2314 matched admissions were analysed. Compared to non-frail patients (CFS 1-4), mortality was higher in all frail patients (CFS 5-8), at 31% vs. 13%, and in frail patients admitted after MET review at 33%. After adjusting for age, APACHE, antecedent MET review and CFS in the Cox regression, mortality hazard ratio increased by 26% per CFS point and by 3% per APACHE III point, while a MET review was not an independent predictor. Limitations of medical treatment occurred in 30% of frail patients, either with or without a MET antecedent, and this was five times higher compared to non-frail patients. Frail patients admitted to ICU have a high short-term mortality. An antecedent MET event was associated with increased mortality but did not independently predict short-term survival when adjusting for confounding factors. The intrinsic significance of frailty should be primarily considered during MET review of frail patients. This study suggests that routine frailty assessment of hospitalised patients would be helpful to set goals of care when admission to ICU could be considered.

Effectiveness of an Artificial Intelligence–Enabled Intervention for Detecting Clinical Deterioration

Inpatient clinical deterioration is associated with substantial morbidity and mortality but may be easily missed by clinicians. Early warning scores have been developed to alert clinicians to patients at high risk of clinical deterioration, but there is limited evidence for their effectiveness. To evaluate the effectiveness of an artificial intelligence deterioration model-enabled intervention to reduce the risk of escalations in care among hospitalized patients using a study design that facilitates stronger causal inference. This cohort study used a regression discontinuity design that controlled for confounding and was based on Epic Deterioration Index (EDI; Epic Systems Corporation) prediction model scores. Compared with other observational research, the regression discontinuity design facilitates causal analysis. Hospitalized adults were included from 4 general internal medicine units in 1 academic hospital from January 17, 2021, through November 16, 2022. An artificial intelligence deterioration model-enabled intervention, consisting of alerts based on an EDI score threshold with an associated collaborative workflow among nurses and physicians. The primary outcome was escalations in care, including rapid response team activation, transfer to the intensive care unit, or cardiopulmonary arrest during hospitalization. During the study, 9938 patients were admitted to 1 of the 4 units, with 963 patients (median [IQR] age, 76.1 [64.2-86.2] years; 498 males [52.3%]) included within the primary regression discontinuity analysis. The median (IQR) Elixhauser Comorbidity Index score in the primary analysis cohort was 10 (0-24). The intervention was associated with a -10.4-percentage point (95% CI, -20.1 to -0.8 percentage points; P = .03) absolute risk reduction in the primary outcome for patients at the EDI score threshold. There was no evidence of a discontinuity in measured confounders at the EDI score threshold. Using a regression discontinuity design, this cohort study found that the implementation of an artificial intelligence deterioration model-enabled intervention was associated with a significantly decreased risk of escalations in care among inpatients. These results provide evidence for the effectiveness of this intervention and support its further expansion and testing in other care settings.

Effect of a person-centred goals-of-care form and clinical communication training on shared decision-making and outcomes in an acute hospital: a prospective longitudinal interventional study.

Patients with a life-limiting illness (LLI) requiring hospitalisation have a high likelihood of deterioration and 12-month mortality. To avoid non-aligned care, we need to understand our patients' goals and values. To describe the association between the implementation of a shared decision-making (SDM) programme and documentation of goals of care (GoC) for hospitalised patients with LLI. A prospective longitudinal interventional study of patients admitted to acute general medicine wards in an Australian tertiary hospital over 5 years was conducted. A SDM programme with a new GoC form, communication training and clinical support was implemented. The primary outcome was the proportion of patients with a documented person-centred GoC discussion (PCD). Clinical outcomes included hospital utilisation and 90-day mortality. 1343 patients were included. The proportion of patients with PCDs increased from 0% to 35.4% (adjusted odds ratio (aOR), 2.38; 95% confidence interval (CI), 2.01-2.82; P < 0.001). During this time, median hospital length of stay decreased from 8 days (interquartile range (IQR), 4-14) to 6 days (IQR, 3-11) (adjusted estimate effect, -0.38; 95% CI, -0.64 to -0.11; P = 0.005) and rapid response team activation from 28% to 13% (aOR, 0.87; 95% CI, 0.78-0.97; P value = 0.01). Documented treatment preference of high-dependency unit care decreased from 39.7% to 24.4% (aOR, 0.81; 95% CI, 0.73-0.89; P value < 0.001), and ward-based care increased from 31.9% to 55.1% (aOR, 1.24; 95% CI, 1.14-1.36; P value < 0.001). The implementation of a SDM programme was associated with increased documentation of person-centred GoC, changed patient treatment preference to lower intensity care and reduced hospital utilisation.

Real-Time Machine Learning Alerts to Prevent Escalation of Care: A Nonrandomized Clustered Pragmatic Clinical Trial.

Machine learning algorithms can outperform older methods in predicting clinical deterioration, but rigorous prospective data on their real-world efficacy are limited. We hypothesized that real-time machine learning generated alerts sent directly to front-line providers would reduce escalations. Single-center prospective pragmatic nonrandomized clustered clinical trial. Academic tertiary care medical center. Adult patients admitted to four medical-surgical units. Assignment to intervention or control arms was determined by initial unit admission. Real-time alerts stratified according to predicted likelihood of deterioration sent either to the primary team or directly to the rapid response team (RRT). Clinical care and interventions were at the providers' discretion. For the control units, alerts were generated but not sent, and standard RRT activation criteria were used. The primary outcome was the rate of escalation per 1000 patient bed days. Secondary outcomes included the frequency of orders for fluids, medications, and diagnostic tests, and combined in-hospital and 30-day mortality. Propensity score modeling with stabilized inverse probability of treatment weight (IPTW) was used to account for differences between groups. Data from 2740 patients enrolled between July 2019 and March 2020 were analyzed (1488 intervention, 1252 control). Average age was 66.3 years and 1428 participants (52%) were female. The rate of escalation was 12.3 vs. 11.3 per 1000 patient bed days (difference, 1.0; 95% CI, -2.8 to 4.7) and IPTW adjusted incidence rate ratio 1.43 (95% CI, 1.16-1.78; p < 0.001). Patients in the intervention group were more likely to receive cardiovascular medication orders (16.1% vs. 11.3%; 4.7%; 95% CI, 2.1-7.4%) and IPTW adjusted relative risk (RR) (1.74; 95% CI, 1.39-2.18; p < 0.001). Combined in-hospital and 30-day-mortality was lower in the intervention group (7% vs. 9.3%; -2.4%; 95% CI, -4.5% to -0.2%) and IPTW adjusted RR (0.76; 95% CI, 0.58-0.99; p = 0.045). Real-time machine learning alerts do not reduce the rate of escalation but may reduce mortality.

Educational Interventions for Rapid Response Team Members: A Narrative Literature Review.

Research continues to be conducted on rapid response systems as patient outcomes associated with rapid response team activations are still not consistently showing benefit. One particular area of focus that is a growing area is the literature regarding training and education for individual team members of the rapid response team. The purpose of this narrative review was to describe the current literature regarding educational interventions for rapid response team members. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. To be included in the narrative review, studies needed to be reporting on educational interventional research for rapid response team members of the efferent limb. No studies were excluded based upon study design or publication years. This narrative review included 6 studies. Four studies assessed outcomes associated with rapid response team members, and 2 of the studies assessed patient outcomes associated with implementing education routinely for rapid response teams. All studies found a positive impact of implementing educational interventions. Our narrative review found that limited research has been conducted in the area of educational interventions for rapid response team members, and of the articles identified, most did not assess patient-associated outcomes. The findings demonstrate that this area of research is in its early stages, and further work is needed to identify what content should be provided in the education and what educational methodologies should be employed, and to continue to assess patient health outcomes associated with educational interventions for rapid response team members.

Academic Half Day Improves Resident Perception of Education Without Compromising Patient Safety

BackgroundResidency programs are required to offer a didactic curriculum and protect resident time for education. Our institution implemented an academic half day (AHD) in the 2021–2022 academic year to address issues related to the standard noon conference series. ObjectiveDetermine the impact of AHD implementation on education, patient safety, and workflow. MethodsThis was a prospective, single-site educational intervention study. Pre- and post-implementation surveys and Accreditation Council for Graduate Medical Education (ACGME) surveys assessed changes in trainee and faculty attitudes and behaviors. Patient safety and workflow were evaluated by comparing the number of safety event reports, rapid response team activations, time to admission from the ED, and time of discharge on AHD days compared to other weekdays. ResultsSurvey response rates were: residents 68%/48%, fellows 42%/35%, and faculty 59%/29%. AHD was associated with a significant, positive change in resident attitudes and experiences and on ACGME survey items. On AHDs compared with other weekdays, there were no significant differences in safety event report rates (P = .98), nor in rapid response team activation rates (P = .99). There was not a clinically meaningful difference in median admission time from the ED on AHD weekdays (125 minutes) compared to other weekdays (130 minutes, P = .04). There was no significant difference in median discharge time on AHD vs other weekdays (P = .13). ConclusionsThis study suggests that there is no significant difference in patient safety or workflow with the implementation of AHD. This study supports prior studies that residents strongly prefer AHD. AHD may be a useful framework for resident education without compromising patient care.

Combining the Nurse Intuition Patient Deterioration Scale with the National Early Warning Score provides more Net Benefit in predicting serious adverse events: A prospective cohort study in medical, surgical, and geriatric wards

ObjectivesThis prospective cohort study aimed to assess the predictive value of the Nurse Intuition Patient Deterioration Scale (NIPDS) combined with the National Early Warning Score (NEWS) for identifying serious adverse events in patients admitted to diverse hospital wards. Research methodology/designData was collected between December 2020 and February 2021 in a 350-bed acute hospital near Brussels, Belgium. The study followed a prospective cohort design, employing NIPDS alongside NEWS for risk assessment. Patients were monitored for 24 h post-registration, with outcomes recorded. SettingThe study was conducted in a hospital with a Rapid Response System (RRS) and electronic patient record wherein NEWS was routinely collected. Patients admitted to two medical, two surgical, and two geriatric wards were included. Main outcome measuresThe primary outcome included death, urgent code calls, or unplanned ICU transfers within 24 h after NIPDS registration. The secondary outcome comprised rapid response team activations or changes in Do-Not-Resuscitate codes. ResultsIn a cohort of 313 patients, 10/313 and 31/313 patients reached the primary and secondary outcome respectively. For the primary outcome, NIPDS had a sensitivity of 0.900 and specificity of 0.927, while NEWS had a sensitivity of 0.300 and specificity of 0.974. Decision Curve Analysis demonstrated that NIPDS provided more Net Benefit across various Threshold Probabilities. Combining NIPDS and NEWS showed potential for optimizing rapid response systems. Especially in resource-constrained settings, NIPDS could be used as a calling criterion. ConclusionThe NIPDS displayed strong predictive capabilities for adverse events. Integrating NIPDS into existing rapid response systems can objectify nurse intuition, enhancing patient safety. Implications for clinical practiceThe Nurse Intuition Patient Deterioration Scale (NIPDS) is a valuable tool for detecting patient deterioration. Implementing NIPDS alongside traditional scores such as NEWS can improve patient care and safety. The optimal NIPDS threshold to activate rapid response is ≥5.

Impact of continuous and wireless monitoring of vital signs on clinical outcomes: a propensity-matched observational study of surgical ward patients

BackgroundContinuous and wireless vital sign monitoring is superior to intermittent monitoring in detecting vital sign abnormalities; however, the impact on clinical outcomes has not been established. MethodsWe performed a propensity-matched analysis of data describing patients admitted to general surgical wards between January 2018 and December 2019 at a single, tertiary medical centre in the USA. The primary outcome was a composite of in-hospital mortality or ICU transfer during hospitalisation. Secondary outcomes were the odds of individual components of the primary outcome, and heart failure, myocardial infarction, acute kidney injury, and rapid response team activations. Data are presented as odds ratios (ORs) with 95% confidence intervals (CIs) and n (%). ResultsWe initially screened a population of 34,636 patients (mean age 58.3 (Range 18–101) yr, 16,456 (47.5%) women. After propensity matching, intermittent monitoring (n=12 345) was associated with increased risk of a composite of mortality or ICU admission (OR 3.42, 95% CI 3.19–3.67; P<0.001), and heart failure (OR 1.48, 95% CI 1.21–1.81; P<0.001), myocardial infarction (OR 3.87, 95% CI 2.71–5.71; P<0.001), and acute kidney injury (OR 1.32, 95% CI 1.09–1.57; P<0.001) compared with continuous wireless monitoring (n=7955). The odds of rapid response team intervention were similar in both groups (OR 0.86, 95% CI 0.79–1.06; P=0.726). ConclusionsPatients who received continuous ward monitoring were less likely to die or be admitted to ICU than those who received intermittent monitoring. These findings should be confirmed in prospective randomised trials.

Iatrogenic Hyperhydration in Sickle Cell Disease Patients Admitted for Acute Pain Crisis Management: A Retrospective Analysis from a Single Institution

Background: Parenteral fluids are an important component of acute pain crisis management in sickle cell disease patients. However, lack of uniform guidelines for fluid replacement coupled with underlying host comorbidities result in risk to patients from complications associated with hyperhydration. Contributing factors include inappropriate choice of fluid, rapid fluid infusion rates with prolonged time periods and inadequate monitoring of signs of hyperhydration. Complications of fluid replacement include excessive weight gain, extremity swelling, pulmonary edema and heart failure. In our study we examined the prevalence of hyperhydration in sickle cell anemia patients admitted for acute pain crisis management at our hospital. Methods: We conducted a retrospective chart review on EPIC of sickle cell anemia patients treated for acute pain crisis in the inpatient unit of John Dempsey Hospital, University of Connecticut between January 2022-December 2022, following IRB approval. To capture patients with signs and symptoms of hyperhydration and its clinical consequences, we looked at surrogate markers such as excessive weight gain during admission, signs of fluid retention, charting of patient fluid intake and output, increased oxygen use, diuretic (Lasix) administration, bronchodilator use, abnormal chest x ray findings indicative of fluid overload pattern, activation of rapid response team for patients developing acute symptoms of fluid overload, and urgent patient transfer to a higher level of care including intensive care unit. Results: 256 admitted patient charts were analyzed representing a total of 95 unique sickle cell disease patients. The median length of hospital stay (LOS) was 3 days. 168 patients had LOS from 3 to 10 days. We observed that 10.7% of the patients experienced an increase in oxygen requirements during their hospital stay. Daily weight was collected in only 27 patients (10.5%) for 3 or more days limiting its usefulness to detect subclinical hyperhydration( figure 1). 69 patients (27%) received parenteral Lasix injection for acute symptoms whose chest x rays also showed pulmonary edema or pleural effusions. 13 patients (18%) were transferred to a higher level of care that included 9 patients to step-down unit and 4 to intensive care for endotracheal intubations and ventilatory support. The median hospital stay was 4 days in patients requiring Lasix compared to 3 days in those who did not. Conclusion : Hyperhydration is undesirable complication associated with fluid administration of sickle cell anemia patients admitted with acute vaso-occlusive pain crisis. It occurs in a significant proportion of affected patients that can result in life threatening complications and prolonged hospitalization. Hyperhydration were missed in this retrospective analysis since daily weight measurements were not available in the majority of patients. Strict charting of fluid intake and output, choice of half normal saline for hydration, as well as clinical monitoring of signs and symptoms of subclinical hyperhydration will help reduce this complication and improve patient outcomes. Improving awareness of this complication among health care providers is important towards achieving this goals. Findings from this study are used to design a prospective quality improvement project in our hospital to improve outcomes and reduce hospitalization in sickle cell anemia patients admitted for acute vaso-occlusive pain crisis.

Abstract 329: Unrecognized Clinical Deterioration Prior to In-Hospital Cardiac Arrest and Associated In-Hospital Mortality

Introduction: Physiologic abnormalities often precede in-hospital cardiac arrest (IHCA). Critical Care Outreach Teams (CCOTs) are designed to respond to patients that meet standardized rapid response team (RRT) activation criteria including vital sign abnormalities, neurologic changes, and nursing concern. However, these systems often rely on clinical staff recognizing signs of clinical deterioration and initiating a rapid response. Research Question: The purpose of this post-hoc analysis was to identify if there was an in-hospital mortality difference between two different adult patient groups: 1) patients who met standardized RRT criteria but did not receive an RRT prior to IHCA and 2) patients who had no evidence of clinical deterioration prior to IHCA. Goals: The primary goal was to explore the association of unrecognized clinical deterioration on patient mortality. A secondary goal was to identify the timing onset of RRT criteria in patients who had an IHCA but did not receive an RRT activation. Methods: All non-ICU IHCAs during a 5-year period (January 1st, 2018, to December 31st, 2022) were reviewed to identify whether: 1) standardized RRT criteria had been met in the 24 hours prior to IHCA, 2) the onset of RRT criteria if present, 3) sustained return of spontaneous circulation (ROSC) occurred during the IHCA, and 4) if the patient died during their hospitalization. Results: There were 271 adult non-ICU IHCAs without a preceding RRT activation. Of those, 203 (79.4%) met RRT criteria prior to IHCA. In patients who had evidence of clinical deterioration, patients displayed at least one RRT criterion an average of 13.1 hours prior to IHCA. Sustained ROSC was higher in the patient group without RRT criteria (79.4%, 54/68 vs 72.9%, 148/203), but this was not significant. In-hospital mortality was significantly higher patients who met RRT criteria without RRT activation compared to patients who did not meet RRT criteria prior to IHCA (67.9%, 65/138 vs 54.4%, 31/37, p&lt;0.05). Conclusions: Most patients who experienced an IHCA demonstrated physiologic abnormalities hours prior to IHCA. Patients who met RRT criteria without RRT activation had a significantly higher mortality rate when compared with patients who did not have evidence of clinical deterioration.

Rapid response team activation prior to in-hospital cardiac arrest: Areas for improvements based on a national cohort study

IntroductionRapid response teams (RRTs) are designed to improve the “chain of prevention” of in-hospital cardiac arrest (IHCA). We studied the 30-day survival of patients reviewed by RRTs within 24 hours prior to IHCA, as compared to patients not reviewed by RRTs. MethodsA nationwide cohort study based on the Swedish Registry of Cardiopulmonary Resuscitation, between January 1st, 2014, and December 31st, 2021. An explorative, hypothesis-generating additional in-depth data collection from medical records was performed in a small subgroup of general ward patients reviewed by RRTs. ResultsIn all, 12,915 IHCA patients were included. RRT-reviewed patients (n = 2,058) had a lower unadjusted 30-day survival (25% vs 33%, p < 0.001), a propensity score based Odds ratio for 30-day survival of 0.92 (95% Confidence interval 0.90–0.94, p < 0.001) and were more likely to have a respiratory cause of IHCA (22% vs 15%, p < 0.001). In the subgroup (n = 82), respiratory distress was the most common RRT trigger, and 24% of the RRT reviews were delayed. Patient transfer to a higher level of care was associated with a higher 30-day survival rate (20% vs 2%, p < 0.001). ConclusionIHCA preceded by RRT review is associated with a lower 30-day survival rate and a greater likelihood of a respiratory cause of cardiac arrest. In the small explorative subgroup, respiratory distress was the most common RRT trigger and delayed RRT activation was frequent. Early detection of respiratory abnormalities and timely interventions may have a potential to improve outcomes in RRT-reviewed patients and prevent further progress into IHCA.

Predictors of Escalation to Intensive Care Unit Level of Care Among Admissions for Alcohol Withdrawal.

According to the 2019 National Survey on Drug Use and Health, 14.5 million people ages 12 and older had alcohol abuse disorder. Alcohol withdrawal syndrome (AWS) can be defined as a collection of physical symptoms experienced due to abrupt cessation of alcohol after long-term dependence. In instances where regular inpatient management fails to control AWS symptoms, patients are shifted to intensive care units (ICUs) for closer monitoring and prevention of life-threatening complications like withdrawal seizures and delirium tremens (DTs), labeled as severe alcohol withdrawal syndrome (SAWS). Although this represents a significant healthcare burden, minimal studies have been conducted to determine objective predictors. In this study, we aim to determine the effect of patient demographics, socio-economic status, biochemical parameters, and clinical factors on the need for escalation to ICU level of care among admissions for AWS. Our study showed that factors such as a history of DTs or alcohol-related seizures, the initial protocol of management, degree of reported alcohol usage, activation of rapid response teams, mean corpuscular value, alcohol level on admission, highest Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) scored during the hospital stay, and the total amount of sedatives used were significantly associated with escalation to ICU level of care. Clinicians must use these objective parameters to identify high-risk patients and intervene early. We encourage further studies to establish a scoring algorithm incorporating biochemical parameters to tailor management algorithms that might better suit high-risk patients.

Systems-Based Physical Assessments: Earlier Detection of Clinical Deterioration and Reduced Mortality.

Despite efforts to improve early detection of deterioration in a patient's condition, delays in activating the rapid response team remain common. To evaluate delays in activating the rapid response team and the occurrence of serious adverse events before and after implementation of a quality improvement initiative aimed at nurses' performing systems-based physical assessments. A retrospective observational cohort design was used to evaluate all patients who had a rapid response team activation during the study period. A total of 1080 patients were included in the analysis: 536 patients before the quality improvement initiative and 544 patients after the quality improvement initiative. The delay in activating the rapid response team decreased from 11.7 hours in the before group to 9.6 hours in the after group (P < .001). In the after group, fewer patients were transferred to the intensive care unit (36% vs 41%, P = .02) and those who were transferred had 3.58 times greater odds of death than those who stayed at the same level of care. The after group had a 44% reduction in the odds of mortality compared with the before group. When nurses focus on conducting a systems-based physical assessment early in their shift, delays in recognizing a patient's deteriorating condition are reduced, fewer patients are admitted to the intensive care unit, and mortality is significantly reduced.

Effect of Implementing a Commercial Electronic Early Warning System on Outcomes of Hospitalized Patients.

Despite the widespread adoption of early warning systems (EWSs), it is uncertain if their implementation improves patient outcomes. The authors report a pre-post quasi-experimental evaluation of a commercially available EWS on patient outcomes at a 700-bed academic medical center. The EWS risk scores were visible in the electronic medical record by bedside clinicians. The EWS risk scores were also monitored remotely 24/7 by critical care trained nurses who actively contacted bedside nurses when a patient's risk levels increased. The primary outcome was inpatient mortality. Secondary outcomes were rapid response team calls and activation of cardiopulmonary arrest (code-4) response teams. The study team conducted a regression discontinuity analysis adjusting for age, gender, insurance, severity of illness, risk of mortality, and hospital occupancy at admission. The analysis included 53,229 hospitalizations. Adjusted analysis showed no significant change in inpatient mortality, rapid response team call, or code-4 activations after implementing the EWS. This study confirms the continued uncertainty in the effectiveness of EWSs and the need for further rigorous examinations of EWSs.

Management Practices for Standard-Risk and High-Risk Patients With Bronchiolitis.

Management guidelines for bronchiolitis advocate for supportive care and exclude those with high-risk conditions. We aim to describe and compare the management of standard-risk and high-risk patients with bronchiolitis. This retrospective study examined patients <2 years of age admitted to the general pediatric ward with an International Classification of Diseases, 10th Revision discharge diagnosis code of bronchiolitis or viral syndrome with evidence of lower respiratory tract involvement. Patients were defined as either standard- or high-risk on the basis of previously published criteria. The frequencies of diagnostic and therapeutic interventions were compared. We included 265 patients in this study (122 standard-risk [46.0%], 143 high-risk [54.0%]). Increased bronchodilator use was observed in the standard-risk group (any albuterol dosing, standard-risk 65.6%, high-risk 44.1%, P = .003). Increased steroid use was observed in the standard-risk group (any steroid dosing, standard-risk 19.7%, high-risk 14.7%, P = .018). Multiple logistic regression revealed >3 doses of albuterol, hypertonic saline, and chest physiotherapy use to be associated with rapid response team activation (odds ratio [OR] >3 doses albuterol: 8.36 [95% confidence interval (CI): 1.99-35.10], P = .048; OR >3 doses hypertonic saline: 13.94 [95% CI: 4.32-44.92], P = .001); OR percussion and postural drainage: 5.06 [95% CI: 1.88-13.63], P = .017). A varied approach to the management of bronchiolitis in both standard-risk and high-risk children occurred institutionally. Bronchodilators and steroids continue to be used frequently despite practice recommendations and regardless of risk status. More research is needed on management strategies in patients at high-risk for severe disease.