Hassan Assareh

The impact of implementing a rapid response system: A comparison of cardiopulmonary arrests and mortality among four teaching hospitals in Australia

AIMS To compare clinical outcomes between a teaching hospital with a mature rapid response system (RRS), with three similar teaching hospitals without a RRS in Sydney, Australia. METHODS For the period 2002-2009, we compared a teaching hospital with a mature RRS, with three similar teaching hospitals without a RRS. Two non-RRS hospitals began implementing the system in 2009 and a third in January 2010. We compared the rates of in-hospital cardiopulmonary arrest (IHCA), IHCA-related mortality, overall hospital mortality and 1-year post discharge mortality after IHCA between the RRS hospital and the non-RRS hospitals based on three separate analyses: (1) pooled analysis during 2002-2008; (2) before-after difference between 2008 and 2009; (3) after implementation in 2009. RESULTS During the 2002-2008 period, the mature RRS hospital had a greater than 50% lower IHCA rate, a 40% lower IHCA-related mortality, and 6% lower overall hospital mortality. Compared to 2008, in their first year of RRS (2009) two hospitals achieved a 22% reduction in IHCA rate, a 22% reduction in IHCA-related mortality and an 11% reduction in overall hospital mortality. During the same time, the mature RRS hospital showed no significant change in those outcomes but, in 2009, it still achieved a crude 20% lower IHCA rate, and a 14% lower overall hospital mortality rate. There was no significant difference in 1-year post-discharge mortality for survivors of IHCA over the study period. CONCLUSIONS Implementation of a RRS was associated with a significant reduction in IHCA, IHCA-related mortality and overall hospital mortality.

Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion

Objectives: To understand the changes in the population incidence of inhospital cardiopulmonary arrest (IHCA) and mortality associated with the introduction of rapid response systems (RRSs).

Delayed Emergency Team Calls and Associated Hospital Mortality: A Multicenter Study.

Objective:We tested the hypothesis that responses to physiologic deterioration in hospital ward patients delayed by more than 15 minutes are associated with increased mortality. Design, Setting, and Participants:We used data from a 23-hospital cluster randomized trial (January 2004 to December 2004) of implementation of rapid response teams (intervention) versus standard practice with conventional cardiac arrest team-based responses to emergencies (control). We examined emergency calls in all hospitals. In intervention hospitals, we also examined such calls in the period before, during the introduction, and after the full implementation of a rapid response system. We studied the statistical association between such delayed calls and mortality. Main Outcomes and Measures:Hospital outcomes (mortality, unplanned ICU admissions, and cardiac arrests). Results:There were 3,135 emergency team calls in all hospitals. Overall, almost one third of such calls were delayed. In intervention hospitals, the proportion of delayed calls was similar before and after implementation of rapid response teams. Compared with control hospitals, in intervention hospitals, there was a significant decrease in the proportion of delayed calls during both the introduction (27.3% vs 34.3% weekly rate; incidence rate ratio, 0.84; p = 0.001) and the full implementation period (29.0% vs 34.5% weekly rate; incidence rate ratio, 0.84; p = 0.023). Delayed calls more likely occurred at night, in high dependence or coronary care units, in patients older than 75 years, in those with a decrease in Glasgow Coma Scale, or in those with hypotension as the reason for the call. Finally, in all hospitals, delayed calls were associated with an increased risk of unplanned ICU admissions (adjusted odds ratio = 1.56; 95% CI, 1.23–2.04; p ⩽ 0.001) and death (adjusted odds ratio = 1.79; 95% CI, 1.43–2.27; p < 0.001). Conclusions:Among ward patients, emergency team activation in response to acute deterioration triggered more than 15 minutes after detection and documentation of instability is independently associated with an increased risk of ICU admission and death.

Planning magnetic resonance imaging for prostate cancer intensity-modulated radiation therapy: Impact on target volumes, radiotherapy dose and androgen deprivation administration.

Magnetic resonance imaging (MRI) scans are increasingly utilized for radiotherapy planning to contour the primary tumors of patients undergoing intensity‐modulated radiation therapy (IMRT). These scans may also demonstrate cancer extent and may affect the treatment plan. We assessed the impact of planning MRI detection of extracapsular extension, seminal vesicle invasion, or adjacent organ invasion on the staging, target volume delineation, doses, and hormonal therapy of patients with prostate cancer undergoing IMRT.

Transcriptome analysis of human brain tissue identifies reduced expression of complement complex C1Q Genes in Rett syndrome

BackgroundMECP2, the gene mutated in the majority of Rett syndrome cases, is a transcriptional regulator that can activate or repress transcription. Although the transcription regulatory function of MECP2 has been known for over a decade, it remains unclear how transcriptional dysregulation leads to the neurodevelopmental disorder. Notably, little convergence was previously observed between the genes abnormally expressed in the brain of Rett syndrome mouse models and those identified in human studies.MethodsHere we carried out a comprehensive transcriptome analysis of human brain tissue from Rett syndrome brain using both RNA-seq and microarrays.ResultsWe identified over two hundred differentially expressed genes, and identified the complement C1Q complex genes (C1QA, C1QB and C1QC) as a point of convergence between gene expression changes in human and mouse Rett syndrome brain.ConclusionsThe results of our study support a role for alterations in the expression level of C1Q complex genes in RTT pathogenesis.

Rate of venous thromboembolism among surgical patients in Australian hospitals: a multicentre retrospective cohort study

Objectives Despite the burden of venous thromboembolism (VTE) among surgical patients on health systems in Australia, data on VTE incidence and its variation within Australia are lacking. We aim to explore VTE and subsequent mortality rates, trends and variations across Australian acute public hospitals. Setting A large retrospective cohort study using all elective surgical patients in 82 acute public hospitals during 2002–2009 in New South Wales, Australia. Participants Patients underwent elective surgery within 2 days of admission, aged between 18 and 90 years, and who were not transferred to another acute care facility; 4 362 624 patients were included. Outcome measures VTE incidents were identified by secondary diagnostic codes. Poisson mixed models were used to derive adjusted incidence rates and rate ratios (IRR). Results 2/1000 patients developed postoperative VTE. VTE increased by 30% (IRR=1.30, CI 1.19 to 1.42) over the study period. Differences in the VTE rates, trends between hospital peer groups and between hospitals with the highest and those with the lowest rates were significant (between-hospital variation). Smaller hospitals, accommodated in two peer groups, had the lowest overall VTE rates (IRR=0.56:0.33 to 0.95; IRR=0.37:0.23 to 0.61) and exhibited a greater increase (64% and 237% vs 19%) overtime and greater between-hospital variations compared to larger hospitals (IRR=8.64:6.23 to 11.98; IRR=8.92:5.49 to 14.49 vs IRR=3.70:3.32 to 4.12). Mortality among patients with postoperative VTE was 8% and remained stable overtime. No differences in post-VTE death rates and trends were seen between hospital groups; however, larger hospitals exhibited less between-hospital variations (IRR=1.78:1.30 to 2.44) compared to small hospitals (IRR>23). Hospitals performed differently in prevention versus treatment of postoperative VTE. Conclusions VTE incidence is increasing and there is large variation between-hospital and within-hospital peer groups suggesting a varied compliance with VTE preventative strategies and the potential for targeted interventions and quality improvement opportunities.

Implementation of multivariate control charts in a clinical setting

BACKGROUND In most clinical monitoring cases there is a need to track more than one quality characteristic. If separate univariate charts are used, the overall probability of a false alarm may be inflated since correlation between variables is ignored. In such cases, multivariate control charts should be considered. PURPOSE This paper considers the implementation and performance of the T(2), multivariate exponentially weighted moving average (MEWMA) and multivariate cumulative sum (MCUSUM) charts in light of the challenges faced in clinical settings. We discuss how to handle incomplete records and non-normality of data, and we provide recommendations on chart selection. DATA SOURCES Our discussion is supported by a case study involving the monitoring of radiation delivered to patients undergoing diagnostic coronary angiogram procedures at St Andrews War Memorial Hospital, Australia. We also perform a simulation study to investigate chart performance for various correlation structures, patterns of mean shifts, amounts of missing data and methods of imputation. CONCLUSIONS The MEWMA and MCUSUM charts detect small to moderate shifts quickly, even when the quality characteristics are uncorrelated. The T(2) chart performs less well overall, although it is useful for rapid detection of large shifts. When records are incomplete, we recommend using multiple imputation.

Bayesian change point detection in monitoring cardiac surgery outcomes.

Precise identification of the time when a clinical process has changed, a control charts signal, enables clinicians to search for a potential special cause more effectively. In this article, we develop a change point estimation method for Bernoulli processes in a Bayesian framework. We apply Bayesian hierarchical models to formulate the change point model and Markov Chain Monte Carlo to obtain posterior distributions of the change point parameters. The performance of the Bayesian estimator is investigated through applications on clinical data. We monitor outcomes of cardiac surgery and angioplasty procedures using Bernoulli exponentially weighted moving average (EWMA) and cumulative sum (CUSUM) control charts. We then identify the time of changes in prior signals obtained from charts. Study of the known potential causes of changes in the outcomes reveals that estimated change points and shifts in the known causes are coincident.

Incidence and Variation of Discrepancies in Recording Chronic Conditions in Australian Hospital Administrative Data.

Diagnostic data routinely collected for hospital admitted patients and used for case-mix adjustment in care provider comparisons and reimbursement are prone to biases. We aim to measure discrepancies, variations and associated factors in recorded chronic morbidities for hospital admitted patients in New South Wales (NSW), Australia. Of all admissions between July 2010 and June 2014 in all NSW public and private acute hospitals, admissions with over 24 hours stay and one or more of the chronic conditions of diabetes, smoking, hepatitis, HIV, and hypertension were included. The incidence of a non-recorded chronic condition in an admission occurring after the first admission with a recorded chronic condition (index admission) was considered as a discrepancy. Poisson models were employed to (i) derive adjusted discrepancy incidence rates (IR) and rate ratios (IRR) accounting for patient, admission, comorbidity and hospital characteristics and (ii) quantify variation in rates among hospitals. The discrepancy incidence rate was highest for hypertension (51% of 262,664 admissions), followed by hepatitis (37% of 12,107), smoking (33% of 548,965), HIV (27% of 1500) and diabetes (19% of 228,687). Adjusted rates for all conditions declined over the four-year period; with the sharpest drop of over 80% for diabetes (47.7% in 2010 vs. 7.3% in 2014), and 20% to 55% for the other conditions. Discrepancies were more common in private hospitals and smaller public hospitals. Inter-hospital differences were responsible for 1% (HIV) to 9.4% (smoking) of variation in adjusted discrepancy incidences, with an increasing trend for diabetes and HIV. Chronic conditions are recorded inconsistently in hospital administrative datasets, and hospitals contribute to the discrepancies. Adjustment for patterns and stratification in risk adjustments; and furthermore longitudinal accumulation of clinical data at patient level, refinement of clinical coding systems and standardisation of comorbidity recording across hospitals would enhance accuracy of datasets and validity of case-mix adjustment.

Use of hypofractionated post‐mastectomy radiotherapy reduces health costs by over

The most recent clinical practice guidelines released by Cancer Australia draw attention to unanswered questions concerning the health economic considerations associated with hypofractionated radiotherapy. This study aimed to quantify and compare the healthcare costs at a regional Australian radiotherapy institute with respect to conventionally fractionated post‐mastectomy radiotherapy (Cf‐PMRT) versus hypofractionated post‐mastectomy radiotherapy (Hf‐PMRT) administration.