Antony Tobin

Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review.

Objective: To determine the long-term impact of a medical emergency team on survival and to assess the utility of administrative data to monitor outcomes. Design: Prospective study of cardiac arrests and survival. Retrospective study of administrative data. Setting: University affiliated tertiary referral hospital in Melbourne, Australia. Patients: All patients admitted to hospital in three 6-month periods between 2002–2007 (prospective) and 1993–2007 (retrospective). Intervention: Implementation of a medical emergency team in November 2002. Measurements and Main Results: In the prospective analysis, rates of unexpected cardiac arrest and hospital mortality (referenced to 1000 patient-care days) were measured before (July–August 2002) and after (December 2002–May 2003, December 2004–May 2005, December 2006–May 2007) the introduction of the medical emergency team. Cardiac arrest rates decreased progressively from 0.78 per 1000 (95% confidence interval, 0.50–1.16) to 0.25 per 1000 (95% confidence interval, 0.15–0.39, p < .001), and hospital mortality from 0.58 per 1000 (95% confidence interval, 0.35–0.92) to 0.30 per 1000 (95% confidence interval, 0.20–0.46, p < .05); cardiac arrest rates achieved statistical significance at 2 yrs and hospital mortality at 4 yrs. Using administrative data adjusted for age, sex, case-mix, and comorbidity, hazard ratios for mortality for the three post implementation periods were statistically lower than for the 10 yrs pre implementation (0.85, 0.74, 0.65). The intensity of calling (calls/1000 patient-days) inversely correlated with cardiac arrest rate, unexpected mortality rate, and total hospital mortality rate. Conclusions: The introduction of a medical emergency team was associated with a progressive decline of unexpected cardiac arrests within 2 yrs, and of unexpected mortality within 4 yrs. This suggests that changes to organizational practice take time and benefits may not be immediately obvious. Such changes are reflected in total hospital mortality measured from administrative data and make monitoring simpler in the longer term. Finally, efforts to increase calling of emergency teams should reduce cardiac arrests and mortality.

An intensivist-led tracheostomy review team is associated with shorter decannulation time and length of stay: a prospective cohort study

IntroductionWithout specific strategies to address tracheostomy care on the wards, patients discharged from the intensive care unit (ICU) with a tracheostomy may receive suboptimal care. We formed an intensivist-led multidisciplinary team to oversee ward management of such patients. To evaluate the service, we compared outcomes for the first 3 years of the service with those in the year preceding the service.MethodsData were prospectively collected over the course of 3 years on ICU patients not under the care of the ear, nose, and throat unit who were discharged to the ward with a tracheostomy and compared with outcomes in the year preceding the introduction of the service. Principal outcomes were decannulation time, length of stay after ICU discharge, and stay of less than 43 days (upper trim point for the disease-related group [DRG] for tracheostomy). Analysis included trend by year and multivariable analysis using a Cox proportional hazards model. P values of less than 0.05 were assumed to indicate statistical significance. As this was a quality assurance project, ethics approval was not required.ResultsTwo hundred eighty patients were discharged with a tracheostomy over the course of a 4-year period: 41 in 2003, 60 in 2004, 95 in 2005, and 84 in 2006. Mean age was 61.8 (13.1) years, 176 (62.9%) were male, and mean APACHE (Acute Physiology and Chronic Health Evaluation) II score was 20.4 (6.4). Length of stay after ICU decreased over time (30 [13 to 52] versus 19 [10 to 34] days; P < 0.05 for trend), and a higher proportion of decannulated patients were discharged under the upper DRG trim point of 43 days (48% versus 66%; P < 0.05). Time to decannulation after ICU discharge decreased (14 [7 to 31] versus 7 [3 to 17] days; P < 0.01 for trend). Multivariate analysis showed that the hazard for decannulation increased by 24% (3% to 49%) per year.ConclusionAn intensivist-led tracheostomy team is associated with shorter decannulation time and length of stay which may result in financial savings for institutions.

Mechanisms by which systemic salbutamol increases ventilation

Background and objective:  Salbutamol (SAL) has systemic effects that may adversely influence ventilation in asthmatic patients. The authors sought to determine the magnitude of this effect and mechanisms by which i.v. SAL affects ventilation.

Medical emergency teams are associated with reduced mortality across a major metropolitan health network after two years service: a retrospective study using government administrative data

IntroductionMedical emergency teams (MET) are implemented to ensure prompt clinical review of patients with deteriorating physiology with the intention of averting further deterioration, cardiac arrest and death. We sought to determine if MET implementation has led to reductions in hospital mortality across a large metropolitan health network utilising routine administrative data submitted by hospitals to the Department of Health Victoria.MethodsThe Victorian admissions episodes data set (VAED) contains data on all individual hospital separations in the State of Victoria, Australia. After gaining institutional ethics approval, we extracted data on all acute admissions to metropolitan hospitals for which we had information on the presence and timing of a MET system. Using logistic regression we determined whether there was an effect of MET implementation on mortality controlling for age, gender, Charlson comorbidity diagnostic groupings, emergency admission, same day admission, ICU admission, mechanical ventilation, year, indigenous ethnicity, liaison nurse service and hospital designation.Results5911533 individual admissions and 73,599 associated deaths from July 1999 to June 2010 were included in the analysis. 52.2% were male and median age was 57(42-72 IQR). Mortality rates for MET and non-MET periods were 3.92 (3.88-3.95 95%CI) and 4.56 (4.51-4.61 95%CI) deaths per 1000 patient days with a rate ratio after adjustment for year of 0.88 (0.86-0.89 95%CI) P < 0.001. In a multivariable logistic regression, mortality was associated with a MET team being active in the hospital for more than 2 years. The odds ratio for mortality in hospitals where a MET system had been in place for greater than 4 years duration was 0.90 (0.88-0.92). Mortality during the first 2 years of a MET system being in place was not statistically different from pre-MET periods.ConclusionsUtilising routinely collected administrative data we demonstrated that the presence of a hospital MET system for greater than 2 years was associated with an independent reduction in hospital mortality across a major metropolitan health network. Mortality benefits after the introduction of a MET system take time to become apparent.

Respiratory failure precipitated by salbutamol.

An 18-year-old woman presented with an asthma exacerbation that initially improved with nebulised salbutamol, an i.v. salbutamol infusion (15 μ g/min) and i.v. corticosteroids. She remained breathless and was transferred to our intensive care unit. On arrival she was talking in short phrases with pulse rate 139, respiratory rate 23 and SpO 2 97% on 4 L/min through nasal prongs. On auscultation there was soft wheeze bilaterally. Initial bloods showed a compensated metabolic acidosis (pH 7.37, pCO 2 28 mmHg, HCO3 – 16 mmol/L, base excess (BE) –8.2), lactate of 7.8 mmol/L, potassium 2.5 mmol/L and glucose 15.2 mmol/L. The salbutamol infusion was ceased but salbutamol was continued by nebuliser (4 × 5 mg/nebuliser) because of ongoing breathlessness. Three hours after admission she became tachypnoeic to 38 and complained of becoming very tired. She then became drowsy, her respiratory rate dropped to the low 20s and her breathing appeared laboured. Blood gases showed a metabolic acidosis with a coexistent respiratory acidosis (pH 7.30, pO2249 mmHg, CO 2 34 mmHg, HCO 3 – 17 mmol/L, BE –8.9), raised lactate (7.4 mmol/L) and hypokalaemia (2.6 mmol/L). She was intubated because of concern of impending respiratory arrest. After intubation, she was easy to ventilate with peak inspiratory pressures of 20–25 cmH 2 O and no recordable intrinsic positive end-expiratory pressure (PEEPi) or gas trapping. Salbutamol therapy was ceased and her lactic acidosis and hyperglycaemia resolved over 6 h (pH 7.33, lactate 1.4 mmol/L, glucose 7.3 mmol/L). She was extubated 14 h after intubation. Expert opinion in Australia 1 supports the addition of i.v. salbutamol by infusion to nebulised β 2-agonist therapy in severe asthma despite the absence of evidence in the published literature to support this and some evidence to the contrary. 2–6 Systemic salbutamol has well described metabolic effects, including hyperglycaemia, hypokalaemia, increased metabolic rate 7 and lactic acidosis. Both lactic acidosis and increased metabolic rate will increase ventilatory demands. If asthma persists, these demands must be met by a respiratory system compromised by airflow obstruction and hyperinflation. As respiratory rate increases to meet demand, dead-space ventilation increases and dynamic hyperinflation worsens, impairing respiratory muscle function and increasing PEEPi (which increases inspiratory work of breathing). Work of breathing is, therefore, increased both by increased demands and by the resultant worsening respiratory mechanics. Ultimately, this may result in fatigue and respiratory failure. In addition, hypokalaemia may also contribute to respiratory muscle dysfunction. 8 (Fig. 1) Failure by clinicians to appreciate these possibilities may lead to inappropriate escalation of β 2-agonists that may paradoxically precipitate respiratory failure. Our case and other case studies 9–11 suggest that this is not just a hypothetical problem. In our opinion, salbutamol should not be given by i.v. infusion to asthmatics. In addition, we believe that it is mandatory for patients who appear unresponsive to nebulised β 2 agonists to have blood gasses performed to exclude paradoxical worsening of breathlessness as a result of the metabolic effects of salbutamol. Finally, for patients who fail to respond to inhaled β 2 agonists, ipratropium and systemic steroids, consideration should be given to other therapies such as non-invasive ventilation 12 rather than increasing the dose of a drug that may, paradoxically, worsen respiratory function.

Do outlier inpatients experience more emergency calls in hospital? An observational cohort study

Objective: To determine the effect of spending time as an outlier (ie, an inpatient who spends time away from his or her “home” ward) on the frequency of emergency calls for patients admitted to a tertiary referral hospital.

Epidemiology of in‐hospital mortality in acute patients admitted to a tertiary level hospital

Healthcare professionals may have difficulty in recognising the dying patient in acute care settings, and yet, this is essential if timely end‐of‐life care is to be provided. While approximately one‐third of patients who pass away in‐hospital are reviewed by the rapid response team (RRT), there is limited available research on other factors associated with mortality within the hospital setting.

The duration of hospitalization before review by the rapid response team: A retrospective cohort study☆

PURPOSE The purpose of this study is to compare cases of rapid response team (RRT) review for early deterioration (<48 hours after admission), intermediate deterioration (48 to <168 hours after admission), late deterioration (≥168 hours after admission), and cardiac arrest and to determine the association between duration of hospitalization before RRT review and mortality. METHODS This is a retrospective cohort study of RRT cases from a single hospital over 5 years (2009-2013) using administrative data and data for the first RRT attendance of each hospital episode. RESULTS Of 2843 RRT cases, 971 (34.2%) were early deterioration, 917 (32.3%) intermediate, 775 (27.3%) late, and 180 (6.3%) cardiac arrest. Compared with early deterioration patients, late deterioration patients were older (median, 71 vs 69 years; P = .005), had a higher Charlson comorbidity index (median, 2 vs 1; P < .001), more often had RRT review for respiratory distress (32.5% vs 23.5%; P < .001), more often received RRT-initiated not for resuscitation orders (8.4% vs 3.9%; P < .001), less often were discharged directly home (27.9% vs 58.4%; P < .001), and more often died in hospital (30.6% vs 12.8%; P < .001). Compared with early deterioration and adjusted for confounders, the odds ratio of death in hospital for late deterioration was 2.36 (1.81-3.08; P < .001). CONCLUSIONS Late deterioration is frequently encountered by the RRT and, compared with early deterioration, is associated with greater clinical complexity and a worse hospital outcome.

Heatwave hyponatraemia: a case series at a single Victorian tertiary centre during January 2014

Heatwaves are a major public health threat for Australians. Hyponatraemia is common, with an increased incidence previously described during heatwaves. We report a series of 10 patients admitted with moderate to profound hyponatraemia, the majority with a history of excess water consumption, during the January 2014 heatwave.

Trends and Outcomes of Chronic Kidney Disease in Intensive Care- a 5 year study

The prevalence of chronic kidney disease (CKD) is increasing in Australia and is independently associated with a higher risk of hospitalisation and death. Australian data may be useful in guiding improved hospital management of this growing cohort of patients.