Rapid Response Team Activation Research Articles

Pediatric Transport-Specific Illness Severity Scores Predict Clinical Deterioration of Transported Patients.

The Transport Risk Assessment in Pediatrics (TRAP) and Transport Pediatric Early Warning Scores (T-PEWS) are transport-specific pediatric illness severity scores that are adjunct assessment tools for determining disposition of transported patients. We hypothesized that these scores would predict the risk of clinical deterioration in transported patients admitted to general pediatric wards. Activation of a rapid response team (RRT) in the first 24 hours of admission was used as a marker of deterioration. All pediatric transports between March 2017 and February 2020 admitted via critical care transport were included. Transports to the emergency department (ED) were excluded. This retrospective chart review evaluated TRAP and T-PEWS scores at 3 points: (1) arrival of transport team at referring hospital, (2) admission to the children's hospital, and (3) RRT activation, if occurring within 24 hours of admission. There were 1137 team transports during this period. Three hundred ninety-nine patients transported to the ED were excluded, leaving 738 included patients; 405 (55%) admitted to the general wards and 333 (45%) admitted to the pediatric intensive care unit. Twenty-five patients admitted to the wards (6%) had an RRT activation within 24 hours of admission. Statistical analysis used 2-sample t tests. There was a statistically significant difference in scores for ward admissions between those who had RRT activation and those who did not. Both TRAP and T-PEWS can be used to predict the risk of clinical deterioration in transported patients admitted to general wards. These scores may assist in assessing which patients admitted to the wards need closer observation.

Modifications to rapid response team (medical emergency team) activation criteria and its impact on patient safety.

Modifications to rapid response team (RRT) activation criteria occur commonly in Australian hospitals without evidence to define their use. To evaluate the effectiveness of RRT activation criteria modifications in preventing RRT activation and differences in adverse events associated with treatment delays caused by modifications. A prospective chart audit of hospital patients with RRT activation criteria modifications admitted during a 12-month period in a large regional hospital in Toowoomba, Australia. The incidence of RRT activation criteria modifications, RRT activations and rates of adverse events following criteria modifications were investigated. Adverse events were defined as a delayed treatment on the ward, unplanned intensive care unit admission, cardiac arrest and unexpected death. Differences in patient outcomes among medical and surgical patients were also investigated. A total of 271 patients out of 4009 admitted patients had modifications to their RRT activation criteria. There was no difference in rates of RRT activation in patients with modified criteria compared with patients with unmodified criteria (P = 0.37). In patients with RRT activation criteria modifications, rates of adverse events were higher in patients who met their modified RRT criteria (93.3%) compared with those who did not meet modified RRT criteria (3.8%; P < 0.001). Additionally, in patients with modifications, rates of adverse events were higher in medical patients (27.6%; n = 50) compared with surgical patients (15.6%; n = 14; P = 0.03). The results strongly suggest that RRT criteria modification is associated with no difference in rates of RRT activation and with detrimental impacts on patient safety, particularly in medical patients.

Characteristics of Children Who Deteriorate After Transport and Associated Preadmission Factors

ObjectiveThe incidence of deterioration and associated characteristics are largely unknown for children transported for admission from referring emergency departments (EDs) to general inpatient units. This study describes this population and identifies associated preadmission characteristics. MethodsThis single-center cohort study included children ≤ 18 years old transferred from an ED and directly admitted to general inpatient units from 2016 to 2019. Deterioration was defined as 1 or more of the following occurring within 24 hours of admission: rapid response team activation, transfer to the intensive care unit (ICU), or cardiac or respiratory arrest. ICU transfer was the secondary outcome. Logistic regression was performed. ResultsOne thousand nine hundred eighty-eight patients were included; the median age was 4.2 years, 53.9% were male, and 44.1% had respiratory diagnoses. Deterioration occurred in 135 (6.8%) children overall and in 10.1% of children with respiratory complaints. Deterioration was associated with ≥ 2 complex chronic conditions (adjusted odds ratio [aOR] = 2.09; 95% confidence interval [CI], 1.04-4.19) and a longer stabilization time (per 10 minutes) (aOR = 1.17; 95% CI, 1.01-1.36). ICU transfer was associated with ≥ 2 complex chronic conditions (aOR = 2.33; 95% CI, 1.13-4.80), supplemental oxygen via nasal cannula (aOR = 2.13; 95% CI, 1.18-3.85), and nebulizer treatment (aOR = 2.77; 95% CI, 1.21-6.35). ConclusionDeterioration was experienced by 7% of children admitted to a general unit, with the majority having respiratory complaints. Transport teams should consider the potential for increased risk of deterioration among children with respiratory disease, multiple complex chronic conditions, and a nasal cannula or nebulizer therapy. The clinical significance of marginally longer stabilization times is unclear and warrants further investigation.

The epidemiology of rapid response team activation amongst patients undergoing major gastrointestinal surgery

BackgroundClinical deterioration requiring rapid response team (RRT) review is associated with increased morbidity amongst hospitalised patients. The frequency of and association with RRT calls in patients undergoing major gastrointestinal surgery is unknown. Understanding the epidemiology of RRT calls might identify areas for quality improvement in this cohort. ObjectivesThe objective of this study is to identify perioperative risks and outcome associations with RRT review following major gastrointestinal surgery. MethodsWe conducted a retrospective cohort study using electronic databases at a large Australian university hospital. We included adult patients admitted for major gastrointestinal surgery between 1 January 2015 and 31 March 2018. ResultsOf 7158 patients, 514 (7.4%) required RRT activation postoperatively. After adjustment, variables associated with RRT activation included the following: hemiplegia/paraplegia (odds ratio [OR]: 8.0, 95% confidence interval [CI]: 2.3 to 27.8, p = 0.001), heart failure (OR: 6.9, 95% CI: 3.3 to 14.6, p < 0.001), peripheral vascular disease (OR: 5.3, 95% CI: 2.7 to 10.4, p < 0.001), peptic ulcer disease (OR: 4.2, 95% CI: 2.2 to 8.0, p < 0.001), chronic obstructive pulmonary disease (OR: 4.0, 95% CI: 2.2 to 7.2, p < 0.001), and emergency admission status (OR: 2.6, 95% CI: 2.1 to 3.3, p < 0.001). Following the index operation, 46% of first RRT activations occurred within 24 h of surgery and 61% had occurred within 48 h. The most common triggers for RRT activation were tachycardia, hypotension, and tachypnoea. Postoperative RRT activation was associated with in-hospital mortality (OR: 6.7, 95% CI: 3.8 to 11.8, p < 0.001), critical care admission (incidence rate ratio: 8.18, 95% CI: 5.23 to 12.77, p < 0.001), and longer median length of hospital stay (12 days vs. 2 days, p < 0.001) compared to no RRT activation. ConclusionAfter major gastrointestinal surgery, one in 14 patients had an RRT activation, almost half within 24 h of surgery. Such activation was independently associated with increased morbidity and mortality. Identified associations may guide more pre-emptive management for those at an increased risk of RRT activation.

The association between unanticipated prolonged post-anaesthesia care unit length of stay and early postoperative deterioration: A retrospective cohort study.

This study aimed to investigate whether there was an association between an unanticipated prolonged post-anaesthesia care unit (PACU) length of stay and early postoperative deterioration, as defined as the need for a rapid response team activation, within the first seven days of surgery. We conducted a single-centre retrospective cohort study of adult surgical patients, who stayed at least one night in hospital, and were not admitted to critical care immediately postoperatively, between 1 July 2017 and 30 June 2019. A total of 11,885 cases were analysed. PACU length of stay was significantly associated with rapid response team activation on both univariate (odds ratio (OR) per increment 1.57, 95% confidence intervals (CI) 1.45 to 1.69, P < 0.001) and multivariate analysis (OR per increment 1.41, 95% CI 1.28 to 1.55, P < 0.001). Patients who stayed less than one hour were at low risk of deterioration (absolute risk 3.7%). In patients staying longer than one hour, the absolute increase in risk was small but observable within six hours of PACU discharge. Compar\ed to a one-hour length of stay, a five-hour stay had a relative risk of 4.9 (95% CI 3.7 to 6.1). Other factors associated with rapid response team activation included non-elective surgery (OR 1.78, P < 0.001) and theatre length of stay (OR per increment 1.61, P < 0.001). PACU length of stay was also independently associated with predefined complications and unplanned intensive care unit admission postoperatively. In our cohort, an unanticipated prolonged PACU length of stay of over one hour was associated with an increased incidence of rapid response team activation in the first seven days postoperatively.

Bedside Clinicians' Perceptions on the Contributing Role of Diagnostic Errors in Acutely Ill Patient Presentation: A Survey of Academic and Community Practice.

This study aimed to explore clinicians' perceptions of the occurrence of and factors associated with diagnostic errors in patients evaluated during a rapid response team (RRT) activation or unplanned admission to the intensive care unit (ICU). A multicenter prospective survey study was conducted among multiprofessional clinicians involved in the care of patients with RRT activations and/or unplanned ICU admissions (UIAs) at 2 academic hospitals and 1 community-based hospital between April 2019 and March 2020. A study investigator screened eligible patients every day. Within 24 hours of the event, a research coordinator administered the survey to clinicians, who were asked the following: whether diagnostic errors contributed to the reason for RRT/UIA, whether any new diagnosis was made after RRT/UIA, if there were any failures to communicate the diagnosis, and if involvement of specialists earlier would have benefited that patient. Patient clinical data were extracted from the electronic health record. A total of 1815 patients experienced RRT activations, and 1024 patients experienced UIA. Clinicians reported that 18.2% (95/522) of patients experienced diagnostic errors, 8.0% (42/522) experienced a failure of communication, and 16.7% (87/522) may have benefitted from earlier involvement of specialists. Compared with academic settings, clinicians in the community hospital were less likely to report diagnostic errors (7.0% versus 22.8%, P = 0.002). Clinicians report a high rate of diagnostic errors in patients they evaluate during RRT or UIAs.

Obstetric Emergencies Requiring Rapid Response Team Activation: A Retrospective Cohort Study in a High-Risk Tertiary Care Centre.

The purpose of this study was to better understand obstetric codes requiring rapid response team activation by examining their incidence, indications, team response, and patient outcomes. This was a retrospective study in peripartum women who required activation of the following codes during hospitalization between January 2014 and May 2018: "Code 77 (C77)" (obstetric emergency), "Code Blue (CB)" (cardiopulmonary compromise) or "Code Omega (CO)" (massive transfusion). Hospital database and health records were searched to identify and review cases. Data on code characteristics, resuscitative measures, and maternal and neonatal outcomes were collected. A total of 147 codes were identified during the study period (C77, 110; CO, 25; CB 12), with an overall incidence of 1 per 203 deliveries (C77, 1:271 deliveries, CO, 1:1194 deliveries; CB, 1:2488 deliveries). Common indications for C77 were cord prolapse (33%) and fetal bradycardia (32%), and for CO and CB, postpartum hemorrhage (84%) and cardiac arrest (42%), respectively. Most codes (67%) occurred after hours. The median decision-to-delivery interval was 8 (interquartile range 5-15) minutes after C77. Emergency cesarean delivery was performed for 57% of obstetric emergencies, and general anesthesia was administered in 63% of cesarean deliveries. Maternal and neonatal mortality rates were 0.68% and 7%, respectively. Major maternal morbidity was seen in 33% of cases. Debrief was documented for 4% of codes. Rapid response team activation was required more commonly in C77 than in CO or CB. Their response time and decision-to-delivery intervals were rapid. Mortality was low; however, one-third of parturients had major morbidities. We suggest closer patient monitoring, immediate availability of resources, and appropriate documentation and debriefing.

Technologies used by nursing to predict clinical deterioration in hospitalized adults: a scoping review.

to map the early clinical deterioration technologies used in nurses' professional practice in the care of hospitalized adult patients. this is a scoping review, according to Joanna Briggs Institute Reviewer's Manual, which seeks to map the main technologies for detecting early clinical deterioration of hospitalized patients available for use by nurses, summarizing them and indicating gaps in knowledge to be investigated. twenty-seven studies were found. The most present variables in the technologies were vital signs, urinary output, awareness and risk scales, clinical examination and nurses' judgment. The main outcomes were activation of rapid response teams, death, cardiac arrest and admission to critical care units. the study emphasizes the most accurate variables in patient clinical assessment, so that indicative signs of potential severity can be prioritized to guide health conducts aiming to intervene early in the face of ongoing clinical deterioration.

Automated documentation of vital parameters in wards using portable stations - Effect on proper triggering of the rapid response team: a study protocol of a cluster randomized clinical trial

OBJECTIVE: To evaluate the effectiveness of the Welch Allyn Connex® Spot Monitor/Hillrom Connecta™ solution in activating the rapid response team in a timely manner compared to manual activation. METHODS: The Hillrom study is a single-center, open-label, superiority, cluster-randomized, parallel-group (1:1 allocation ratio) clinical trial that will be conducted in a tertiary hospital. Two sets of three wards with 28 beds will be included (one as the intervention cluster and the other as the control). The wards will be randomly assigned to use the Welch Allyn Connex® Spot Monitor/Hillrom Connecta™ automated solution (intervention cluster) or to maintain the usual routine (control cluster) regarding rapid response team activation. The primary outcome will be the absolute number of episodes of rapid response team triggering in an appropriate time; as secondary outcomes, clinical features (mortality, cardiac arrest, need for intensive care unit admission and duration of hospitalization) will be assessed according to clusters in an exploratory way. A sample size of 216 rapid response team activations was estimated to identify a possible difference between the groups. The protocol has been approved by the institutional Research Ethics Committee. EXPECTED RESULTS: The Welch Allyn Connex® Spot Monitor/Hillrom Connecta™ automated solution is expected to be more effective in triggering the nurse call system to activate the rapid response team in a timely and adequate manner compared to manual triggering (usual practice). CLINICALTRIALS.GOV: NCT04648579

Reducing PICU-to-Floor Time-to-Transfer Decision in Critically Ill Bronchiolitis Patients using Quality Improvement Methodology.

Specific criteria for de-escalation from the PICU are often not included in viral bronchiolitis institutional pathways. Variability of transfer preferences can prolong PICU length of stay. We aimed to decrease the time from reaching floor-appropriate heated high flow nasal cannula (HHF) settings to the transfer decision by 20% through standardizing PICU-to-floor transfer assessment in a PICU bronchiolitis cohort. We included PICU bronchiolitis admissions from October 2019 to April 2020, who were 6-months to 2-years-old with no comorbidities nor intubation during their encounter. Our intervention bundle included introduction of transfer criteria and standardization of transfer-readiness assessment. The primary outcome was time from reaching floor-appropriate HHF settings [8 L per minutes (Lpm)] to placement of the transfer order ("time-to-transfer decision"). The secondary outcome was PICU length of stay. The main process measure was the proportion of patients transferred on ≥6 Lpm HHF. Balancing measures included Rapid Response Team activation and unplanned PICU readmission. We assessed admissions meeting inclusion criteria from December, 2018-March, 2019 for the preintervention baseline. Special cause variation indicated improvement in our primary outcome and process measures. Comparison of baseline to postintervention revealed a reduction in median time-to-transfer decision (14.4-7.8 hours; P < 0.001) and increase in children transferred on ≥6 Lpm (51%-72%; P < 0.001). We observed no change in PICU length of stay or balancing measures. Standardizing de-escalation criteria and transfer-readiness assessment reduced the time-to-transfer decision out of the PICU and increased the proportion transferred on ≥6 Lpm HHF for children with viral bronchiolitis without increasing PICU readmissions.

Effectiveness of Rapid Response Team on In-hospital Mortality in Patients with Hematologic Malignancy

Purpose: Patients with hematologic malignancy (HM) typically have a high mortality rate when their condition deteriorates. The chronic progressive course of the disease makes it difficult to assess the effect of intervention on acute events. We investigated the effectiveness of a rapid response team (RRT) on in-hospital mortality in patients with HM. Methods: We retrospectively analyzed the data of patients with HM who admitted to the medical intensive care unit between 2006 and 2015. Clinical outcomes before and after RRT implementation were evaluated.Results: A total of 228 patients in the pre-RRT period and 781 patients in the post-RRT period were included. The overall in-hospital mortality was 55.4%. Patients in the post-RRT period had improved survival; however, they required more vasopressor therapy, continuous renal replacement therapy, and extracorporeal membrane oxygenation. Multivariate analysis revealed that in-hospital mortality was associated with RRT activation (hazard ratio [HR], 0.634; 95% confidence interval [CI], 0.498–0.807; p &lt; .001), neurological disease (HR, 2.007; 95% CI, 1.439–2.800; p &lt; .001), sequential organ failure assessment score (HR, 1.085; 95% CI, 1.057–1.112; p &lt; .001), need for continuous renal replacement therapy (HR, 1.608; 95% CI, 1.206–1.895; p&lt; .001), mechanical ventilation (HR, 1.512; 95% CI, 1.206–1.895; p&lt; .001), vasopressor (HR, 1.598; 95% CI, 1.105–2.311; p = .013), and extracorporeal membrane oxygenation (HR, 1.728; 95% CI, 1.105–2.311; p = .030).Conclusion: RRT activation may be associated with improved survival in patients with HM.

Impact of a continuous enhanced cardio-respiratory monitoring pathway on cardio-respiratory complications after bariatric surgery: A retrospective cohort study

Study objectiveTo determine the impact of an enhanced monitoring pathway consisting of continuous postoperative cardio-respiratory monitoring on adverse outcomes after bariatric. DesignSingle-center, retrospective cohort study. PatientsAdult patients who underwent bariatric surgeries between 2009 and 2016. InterventionsWe evaluated the use of an enhanced monitoring pathway consisting of a distant, continuous, non-invasive respiratory monitoring system on postoperative cardio-respiratory complications in patients undergoing bariatric surgery. Treating physicians had the option to assign patients to enhanced monitoring (intervention group) in the postoperative period for suspected or diagnosed OSA or other clinical concerns. The control group had intermittent vital sign checks as per institutional standards. MeasurementsThe primary outcome was a composite of cardio-respiratory complications (rapid response team activation, intensive care admission, respiratory complications), major adverse cardiac events, and all-cause mortality. The secondary outcome was length of stay (LOS). Main resultsOf 1450 patients, 752 patients received enhanced monitoring (intervention) and 698 patients received standard monitoring (control). Univariate analysis showed that, compared to control, enhanced monitoring was associated with lower odds of composite cardio-respiratory complications (OR: 0.41, 95%CI: 0.32–0.53, p < 0.001) and lower odds of prolonged LOS > 2 days (OR: 0.37, 95% CI: 0.28–0.49, p < 0.001. After adjusting for potential confounders, enhanced monitoring remained associated with a reduction in composite cardio-respiratory complications (OR: 0.64, 95% CI: 0.46–0.88, p = 0.005). ConclusionsOur study demonstrates that postoperative enhanced monitoring pathway was associated with a lower incidence of cardio-respiratory composite events, compared to a standard of care, in patients undergoing bariatric surgery. As our results show association rather than causation, future prospective randomized trials are needed to confirm the benefit of enhanced monitoring. Findings of our study add to the existing literature involved in clinical management pathways to reduce the incidence of adverse postoperative outcomes in high-risk patients undergoing inpatient surgeries.

Rapid response team activation after major hip surgery: A case series.

IntroductionWe describe the demographic, preoperative, surgical, anesthetic, and postoperative characteristics of patients who required a rapid response team (RRT) activation after major hip surgery. We determined the characteristics and outcomes of patients that require RRTs after major hip surgery, and their associations with mortality.Presentation of casesWe retrospectively reviewed adult patients undergoing major hip surgery in a university teaching hospital. We included patients who had an RRT or “code blue” activation post-surgery and within the index hospital admission. We extracted patient, surgical, anesthetic, and postoperative variables. We explored differences between patients who survived their index hospital stay and those who died.Discussion187 (9%) patients had a postoperative RRT activation. The median age was 84.0 (78–90) years; 125 (67%) were female, and most patients had significant comorbidities. The median Charlson Comorbidity Index (CCI) was 5.0 (4.0–7.0). Patients were frail (68%), ASA physical status ≥Class 3 (91%) and underwent emergency surgery (88%). Death after RRT activation occurred in 1 in 7 patients. Compared to patients who survived RRT activation, those who died had a higher mean CCI (6.5 [1.8] vs. 5.5 [2.1], P = 0.02), were more frail (80.1% vs. 56.5%, OR = 3.2, 95% CI: 1.2,8.1; P = 0.03), and received less intraoperative opioids (intravenous morphine equi-analgesia: median = 5.8 (0.1–8.20 vs. 11.7 (3.7–19.0) mg, P = 0.03).ConclusionMortality after RRT activation is associated with non-modifiable patients factors rather than surgical or anesthesia factors. Our findings provide opportunities for the implementation of strategies aimed at improving postoperative outcomes.

1231: NURSING ASSESSMENT REDUCES DELAYS IN RAPID RESPONSE TEAM ACTIVATION, ICU ADMISSIONS, AND MORTALITY

1231: NURSING ASSESSMENT REDUCES DELAYS IN RAPID RESPONSE TEAM ACTIVATION, ICU ADMISSIONS, AND MORTALITY

Outcomes of second-tier rapid response activations in a tertiary referral hospital: A prospective observational study

A second-tier rapid response team (RRT) is activated for patients who do not respond to first-tier measures. The premise of a tiered response is that first-tier responses by a ward team may identify and correct early states of deterioration or establish goals of care, thereby reducing unnecessary escalation of care to the RRT. Currently, utilisation and outcomes of tiered RRTs remain poorly described. A prospective observational study of adult patients (age ≥18 years) who required RRT activations was conducted from February 2018 to December 2019. There were 951 consecutive RRT activations from 869 patients and 76.0% patients had a National Early Warning Score (NEWS) ≥5 at the time of RRT activation. The majority (79.8%) of patients required RRT interventions that included endotracheal intubation (12.7%), point-of-care ultrasound (17.0%), discussing goals of care (14.7%) and intensive care unit (ICU) admission (24.2%). Approximately 1 in 3 (36.6%) patients died during hospitalisation or within 30 days of RRT activation. In multivariate analysis, age ≥65 years, NEWS ≥7, ICU admission, longer hospitalisation days at RRT activation, Eastern Cooperative Oncology Group performance scores ≥3 (OR [odds ratio] 2.24, 95% CI [confidence interval] 1.45-3.46), metastatic cancer (OR 2.64, 95% CI 1.71-4.08) and haematological cancer (OR 2.78, 95% CI 1.84-4.19) were independently associated with mortality. Critical care interventions and escalation of care are common with second-tier RRTs. This supports the need for dedicated teams with specialised critical care services. Poor functional status, metastatic and haematological cancer are significantly associated with mortality, independent of age, NEWS and ICU admission. These factors should be considered during triage and goals of care discussion.

A Qualitative Analysis of Observed Behavior of Pediatric Rapid Response Team Performance.

Pediatric rapid response teams (RRTs) enhance patient safety, reduce cardiorespiratory arrests outside the PICU, and detect deteriorating patients before decompensation. RRT performance may be affected by failures in communication, poor team dynamics, and poor shared decision-making. We aimed to describe factors associated with team performance using direct observation of pediatric RRTs. Our team directly observed 73 in situ RRT activations, collected field notes of qualitative data, and analyzed the data using conventional content analysis. To assess accuracy of coding, 20% of the coded observations were reassessed for interrater reliability. The codes influencing team performance were categorized as enhancers or threats to RRT teamwork and organized under themes. We constructed a framework of the codes and themes, organized along a spectrum of orderly versus chaotic RRTs. Three themes influencing RRT performance were teamwork, leadership, and patient and family factors, with underlying codes that enhanced or threatened RRT performance. Novel factors that were found to threaten team performance included indecision, disruptive behavior, changing leadership, and family or patient distress. Our framework delineating features of orderly and chaotic RRTs may be used to inform training and design of RRTs to optimize performance. Observations of in situ RRT activations in a pediatric hospital both verified previously described characteristics of RRTs and identified new characteristics of team function. Our proposed framework for understanding these enhancers and threats may be used to inform future interventions to improve RRT performance.

Evaluation and Perception of Clinical Pharmacist Participation in a Rapid Response Team During Cardiopulmonary Resuscitation.

The addition of a pharmacist to rapid response teams (RRT) has been shown to improve adherence to advanced cardiac life support protocols and to decrease mortality. A quality improvement study was initiated at a single center to evaluate the addition of a pharmacist to the RRT during cardiopulmonary arrest. Data were prospectively collected on pharmacy response time and interventions performed. In addition, a pre- and post-intervention survey of the interprofessional medical emergency response improvement team (MERIT) was performed to assess the perception of pharmacist involvement. From April to November 2019, the pharmacists responded to 19 RRT activations for cardiopulmonary arrest. An average of 29.8 minutes were spent at each event and an average of 5.5 interventions per event were made. The most common intervention made by pharmacists was medication procurement (54 interventions), followed by providing drug information (14 interventions). Pharmacists also ensured medication reimbursement (13 interventions). The majority of the MERIT strongly agreed or agreed that the addition of a pharmacist to RRT activations improved teamwork (83.1%), decreased medication turnaround time (84.6%), decreased medication errors (66.7%), and may have prevented a poor outcome (71.8%) in the post-implementation survey. Overall, pharmacists demonstrated value as a member of the RRT during cardiopulmonary arrest. The addition of a pharmacist was well received by interprofessional members of the MERIT.

304 Lack of Early Left Ventricular Outflow Tract Velocity Time Integral Estimated Volume Responsiveness is Associated With Increased Morbidity and Mortality

Fluid boluses are amongst the strongest recommendations for the management of septic patients, and they are generally administered with the goal increasing cardiac output and improving tissue perfusion. Early identification of volume responsiveness is challenging and dependent on many patient factors, but it may prevent the harmful consequences of hypervolemia. Left ventricular outflow tract (LVOT) velocity time integral (VTI) has been used as a predictor of volume responsiveness. The purpose of this study was to determine whether lack of volume responsiveness, defined as ≤15% change in LVOT VTI, is associated with increased risk of mortality, admission to an intensive care unit (ICU), or rapid response team activation within 24 hours of hospital arrival (composite outcome measure). We hypothesize that septic patients who are not volume responders will be more critically ill and therefore at greater risk of experiencing the composite outcome. This is a prospective observation study of septic patients conducted in an academic emergency department (ED). Patients were eligible for enrollment if they met Sepsis 3 definition and were receiving intravenous fluids. Patients received a point-of-care echocardiogram to measure LVOT VTI. Three measurements were taken and the average was recorded. After patients received a 500mL fluid bolus, a repeat ultrasound was conducted to re-measure VTI. Volume responsiveness was defined as >15% increase in VTI. Chart review was performed on all enrolled patients to determine whether the composite outcome occurred within 24 hours of ED arrival. At total of 126 patients with repeat ultrasound exams were included in this analysis; 49.2% were female and median age was 74 years. Overall, 56 (44.4%) patients experienced the composite primary outcome within 24 hours, and 30 (23.8%) patients had a delta VTI of >15%. Among the patients who experienced the composite outcome, 82.1% of them had a delta VTI of ≤15%, compared with 71.4% of patients who did not experience the composite outcome (p-value = 0.160). In a multivariable logistic regression modeling adjusting for lactate and systolic blood pressure, delta VTI of ≤15%, compared with delta VTI >15%, was significantly associated with higher odds of mortality, ICU admission, or rapid response team activation within 24 hours (OR: 2.643; 95% CI: 1.002, 6.967). Septic ED patients who are not volume responsive, based on percent change in VTI, are more likely to experience mortality, be admitted to an ICU, or have a rapid response team activation within 24 hours of ED arrival. Our findings suggest that early VTI may be used in septic patients to predict their clinical course. Future endeavors may evaluate if initial change in VTI could be used to help emergency physicians identify this critically ill cohort and facilitate earlier ICU disposition and vasopressor administration.

The impact of wearable continuous vital sign monitoring on deterioration detection and clinical outcomes in hospitalised patients: a systematic review and meta-analysis

BackgroundTimely recognition of the deteriorating inpatient remains challenging. Wearable monitoring systems (WMS) may augment current monitoring practices. However, there are many barriers to implementation in the hospital environment, and evidence describing the clinical impact of WMS on deterioration detection and patient outcome remains unclear.ObjectiveTo assess the impact of vital-sign monitoring on detection of deterioration and related clinical outcomes in hospitalised patients using WMS, in comparison with standard care.MethodsA systematic search was conducted in August 2020 using MEDLINE, Embase, CINAHL, Cochrane Database of Systematic Reviews, CENTRAL, Health Technology Assessment databases and grey literature. Studies comparing the use of WMS against standard care for deterioration detection and related clinical outcomes in hospitalised patients were included. Deterioration related outcomes (primary) included unplanned intensive care admissions, rapid response team or cardiac arrest activation, total and major complications rate. Other clinical outcomes (secondary) included in-hospital mortality and hospital length of stay. Exploratory outcomes included alerting system parameters and clinical trial registry information.ResultsOf 8706 citations, 10 studies with different designs met the inclusion criteria, of which 7 were included in the meta-analyses. Overall study quality was moderate. The meta-analysis indicated that the WMS, when compared with standard care, was not associated with significant reductions in intensive care transfers (risk ratio, RR 0.87; 95% confidence interval, CI 0.66–1.15), rapid response or cardiac arrest team activation (RR 0.84; 95% CI 0.69–1.01), total (RR 0.77; 95% CI 0.44–1.32) and major (RR 0.55; 95% CI 0.24–1.30) complications prevalence. There was also no statistically significant association with reduced mortality (RR 0.48; 95% CI 0.18–1.29) and hospital length of stay (mean difference, MD − 0.09; 95% CI − 0.43 to 0.44).ConclusionThis systematic review indicates that there is no current evidence that implementation of WMS impacts early deterioration detection and associated clinical outcomes, as differing design/quality of available studies and diversity of outcome measures make it difficult to reach a definite conclusion. Our narrative findings suggested that alarms should be adjusted to minimise false alarms and promote rapid clinical action in response to deterioration.PROSPERO Registration number: CRD42020188633.

89 Predictors of Early Clinical Deterioration from the Emergency Department and Clinical Gestalt: A Prospective Case-Control Study

Rapid response teams (RRT) aim to reduce morbidity and mortality of hospitalized patients through early intervention on those who are clinically deteriorating. Identifying predictors of early deterioration of patients may improve quality and safety. Abnormal vital signs (VS) have previously been studied as predictors of early deterioration and increased RRT activation after admission from the ED. The primary objective is to identify these predictors of RRT activation within 24 hours of admission. Secondary objectives are to detect differences in hospital length-of-stay (LOS), admitting diagnoses, and 30-day mortality in those with and without RRT (+RRT and –RRT). Last, we examine the predictive value of physician clinical gestalt on RRTs. This was a prospective, observational case-control study by chart review of adult patients admitted at Kaweah Health Medical Center between December 2020 and March 2021. Exclusion criteria were age <18, admission to ICU, and direct transfer out of the ED. At time of admission, we performed chart review to collect eight VS used to activate a RRT at our hospital. To determine clinician gestalt, the physician was also asked if RRT would occur within 24 hours. Each patient’s hospital course was later reviewed for the occurrence of RRT, admitting diagnoses, LOS, and 30-day mortality. Categorical variables were analyzed using Fisher’s exact test. Noncategorical variables were analyzed using Wilcoxon rank sum test, independent T-test, and Pearson correlation coefficient. Predictive value was analyzed with negative and positive predictive values (NPV and PPV), sensitivity, and specificity. 199 patients met inclusion/exclusion criteria for analysis (+RRT N=3, -RRT N=196). No significant differences were detected in sex, age, or level of care between our groups. The groups differed in median heart rate and respiratory rate, but the difference was insignificant. There was a marginally significant association between COVID-19 as admitting diagnosis and RRT (p=0.052). There was no significant association between RRT and 30-day mortality. Mean LOS did not differ between the groups (p=0.297). The mean number of abnormal VS in those deceased at 30 days (1.2) was significantly higher than those alive at 30 days (0.7) (p=0.047, correlation coefficient r=0.14). Analysis of clinical gestalt on RRT showed PPV 3.2%, NPV 98.8%, sensitivity 33.3%, and specificity 84.5%. Due to small sample size, our results did not show significant differences in sex, age, level of care, heart rate, respiratory rate, or LOS between the +RRT and –RRT groups. However, our study was significant for three findings. First, there was a marginally significant association between an admitting diagnosis of COVID-19 and RRT. Second, patients deceased within 30 days had a significantly higher number of abnormal VS than patients who were alive at 30 days, suggesting a positive correlation. Third, results suggest that the clinical gestalt of emergency physicians at predicting who will not have an RRT is reasonably good, but may not be as good at predicting who will have an RRT. Further studies determining other factors contributing to early deterioration can help craft interventions to improve patient safety.