Jeffrey Jensen

Delayed Rapid Response Team Activation Is Associated With Increased Hospital Mortality, Morbidity, and Length of Stay in a Tertiary Care Institution.

Objective:To identify whether delays in rapid response team activation contributed to worse patient outcomes (mortality and morbidity). Design:Retrospective observational cohort study including all rapid response team activations in 2012. Setting:Tertiary academic medical center. Patients:All those 18 years old or older who had a rapid response team call activated. Vital sign data were abstracted from individual patient electronic medical records for the 24 hours before the rapid response team activation took place. Patients were considered to have a delayed rapid response team activation if more than 1 hour passed between the first appearance in the record of an abnormal vital sign meeting rapid response team criteria and the activation of an rapid response team. Interventions:None. Measurements and Main Results:A total of 1,725 patients were included in the analysis. Data were compared between those who had a delayed rapid response team activation and those who did not. Fifty seven percent patients met the definition of delayed rapid response team activation. Patients in high-frequency physiologic monitored environments were more likely to experience delay than their floor counterparts. In the no-delay group, the most common reasons for rapid response team activation were tachycardia/bradycardia at 29% (217/748), respiratory distress/low SpO2 at 28% (213/748), and altered level of consciousness at 23% (170/748) compared with respiratory distress/low SpO2 at 43% (423/977), tachycardia/bradycardia at 33% (327/977), and hypotension at 27% (261/977) in the delayed group. The group with no delay had a higher proportion of rapid response team calls between 8:00 and 16:00, whereas those with delay had a higher proportion of calls between midnight and 08:00. The delayed group had higher hospital mortality (15% vs 8%; adjusted odds ratio, 1.6; p = 0.005); 30-day mortality (20% vs 13%; adjusted odds ratio, 1.4; p = 0.02); and hospital length of stay (7 vs 6 d; relative prolongation, 1.10; p = 0.02) compared with the no-delay group. Conclusions:Delays in rapid response team activation occur frequently and are independently associated with worse patient mortality and morbidity outcomes.

Widely used track and trigger scores: Are they ready for automation in practice?

INTRODUCTION Early Warning Scores (EWS) are widely used for early recognition of patient deterioration. Automated alarm/alerts have been recommended as a desirable characteristic for detection systems of patient deterioration. We undertook a comparative analysis of performance characteristics of common EWS methods to assess how they would function if automated. METHODS We evaluated the most widely used EWS systems (MEWS, SEWS, GMEWS, Worthing, ViEWS and NEWS) and the Rapid Response Team (RRT) activation criteria in use in our institution. We compared their ability to predict the composite outcome of Resuscitation call, RRS activation or unplanned transfer to the ICU, in a time-dependent manner (3, 8, 12, 24 and 36 h after the observation) by determining the sensitivity, specificity and positive predictive values (PPV). We used a large vital signs database (6,948,689 unique time points) from 34,898 unique consecutive hospitalized patients. RESULTS PPVs ranged from less than 0.01 (Worthing, 3 h) to 0.21 (GMEWS, 36 h). Sensitivity ranged from 0.07 (GMEWS, 3 h) to 0.75 (ViEWS, 36 h). Used in an automated fashion, these would correspond to 1040-215,020 false positive alerts per year. CONCLUSIONS When the evaluation is performed in a time-sensitive manner, the most widely used weighted track-and-trigger scores do not offer good predictive capabilities for use as criteria for an automated alarm system. For the implementation of an automated alarm system, better criteria need to be developed and validated before implementation.

The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-center study.

Objectives:To determine the impact of rapid response team implementation on the outcome of patients transferred from the regular hospital ward and nonward locations to the ICU. Design:Retrospective before–after cohort study. Setting:The study was performed in two ICUs, one surgical and one medical, of a tertiary medical center. Patients:We included 4,890 patients transferred from the hospital ward to two ICUs and 15,855 patients admitted from nonward locations. Interventions:None. Measurements and Main Results:Data on each patient were abstracted from the Acute Physiology and Chronic Health Evaluation III and the administrative hospital and rapid response team databases. The study period was divided into pre–rapid response team and rapid response team. A 24/7 critical care consult service and cardiac arrest teams were available for ward patient care during both periods. A total of 20,745 patients were admitted to the two study ICUs, of whom 4,890 were from the ward (2,466 and 2,424 during the pre–rapid response team and rapid response team periods, respectively). The first ICU day severity of illness was higher for the pre–rapid response team period. A multiple logistic regression model that included predicted mortality as a covariate suggested that availability of rapid response team was associated with an increased risk of hospital death in patients transferred to the ICU from the regular ward, odds ratio (95% CI) of 1.273 (1.089–1.490). For the nonward patients, the availability of rapid response team was similarly associated with increased risk of death. The ICU length of stay was shorter during the rapid response team period both in ward transfer and in nonward transfer patients. Conclusions:Rapid response team implementation is associated with increased numbers of ICU admissions and rates, and transfer from the ward of less severely ill patients. However, rapid response team implementation did not improve the severity-of-illness-adjusted outcome of patients transferred from the ward. Implementation of rapid response team in an institution with a 24/7 ICU consult service may have unforeseen costs without obvious benefit. Our findings highlight that institutions should evaluate the impact of rapid response team on patient outcome and make modifications specific to their practices.

Evaluating implementation of a rapid response team: Considering alternative outcome measures

OBJECTIVE Determine the prolonged effect of rapid response team (RRT) implementation on failure to rescue (FTR). DESIGN Longitudinal study of institutional performance with control charts and Bayesian change point (BCP) analysis. SETTING Two academic hospitals in Midwest, USA. PARTICIPANTS All inpatients discharged between 1 September 2005 and 31 December 2010. INTERVENTION Implementation of an RRT serving the Mayo Clinic Rochester system was phased in for all inpatient services beginning in September 2006 and was completed in February 2008. MAIN OUTCOME MEASURE Modified version of the AHRQ FTR measure, which identifies hospital mortalities among medical and surgical patients with specified in-hospital complications. RESULTS A decrease in FTR, as well as an increase in the unplanned ICU transfer rate, occurred in the second-year post-RRT implementation coinciding with an increase in RRT calls per month. No significant decreases were observed pre- and post-implementation for cardiopulmonary resuscitation events or overall mortality. A significant decrease in mortality among non-ICU discharges was identified by control charts, although this finding was not detected by BCP or pre- vs. post-analyses. CONCLUSIONS Reduction in the FTR rate was associated with a substantial increase in the number of RRT calls. Effects of RRT may not be seen until RRT calls reach a sufficient threshold. FTR rate may be better at capturing the effect of RRT implementation than the rate of cardiac arrests. These results support prior reports that short-term studies may underestimate the impact of RRT systems, and support the need for ongoing monitoring and assessment of outcomes to facilitate best resource utilization.

The role of the primary care team in the rapid response system

PURPOSE The purpose of the study is to evaluate the impact of primary service involvement on rapid response team (RRT) evaluations. MATERIALS AND METHODS The study is a combination of retrospective chart review and prospective survey-based evaluation. Data included when and where the activations occurred and the patients code status, primary service, and ultimate disposition. These data were correlated with survey data from each event. A prospective survey evaluated the primary teams involvement in decision making and the overall subjective quality of the interaction with primary service through a visual analog scale. RESULTS We analyzed 4408 RRTs retrospectively and an additional 135 prospectively. The primary teams involvement by telephone or in person was associated with significantly more transfers to higher care levels in retrospective (P < .01) and prospective data sets. Code status was addressed more frequently in primary team involvement, with more frequent changes seen in the retrospective analysis (P = .01). Subjective ratings of communication by the RRT leader were significantly higher when the primary service was involved (P < .001). CONCLUSIONS Active primary team involvement influences RRT activation processes of care. The RRT role should be an adjunct to, but not a substitute for, an engaged and present primary care team.

Simulation and Continuing Professional Development.

Since 2000, diplomates of the American Board of Anesthesiology (ABA) have been required to follow a structured process known as Maintenance of Certification in Anesthesiology (MOCA). This comprehensive program integrates multiple educational components, including mannequin-based simulation. Lifelong learning, or Continuous Professional Development (CPD), is a responsibility for any profession, especially a physician. Historically, simulation has been predominantly applied in teaching new physicians, yet over the past decade its role as a tool for educating practicing physicians has evolved, and is now an integral component of MOCA. It is informative to understand the ways that simulation education application varies for practicing physicians compared with trainees, and some of the drivers of that difference. Simulation has utility in helping established physicians learn new techniques and skills and rehearse for uncommon emergencies.

Reliability and validity of the checklist for early recognition and treatment of acute illness and injury as a charting tool in the medical intensive care unit

Background: Resuscitation of critically ill patients is complex and potentially prone to diagnostic errors and therapeutic harm. The Checklist for early recognition and treatment of acute illness and injury (CERTAIN) is an electronic tool that aims to provide decision-support, charting, and prompting for standardization. This study sought to evaluate the validity and reliability of CERTAIN in a real-time Intensive Care Unit (ICU). Materials and Methods: This was a prospective pilot study in the medical ICU of a tertiary care medical center. A total of thirty patient encounters over 2 months period were charted independently by two CERTAIN investigators. The inter-observer recordings and comparison to the electronic medical records (EMR) were used to evaluate reliability and validity, respectively. The primary outcome was reliability and validity measured using Cohens Kappa statistic. Secondary outcomes included time to completion, user satisfaction, and learning curve. Results: A total of 30 patients with a median age of 59 (42–78) years and median acute physiology and chronic health evaluation III score of 38 (23–50) were included in this study. Inter-observer agreement was very good (κ = 0.79) in this study and agreement between CERTAIN and the EMR was good (κ = 0.5). CERTAIN charting was completed in real-time that was 121 (92–150) min before completion of EMR charting. The subjective learning curve was 3.5 patients without differences in providers with different levels of training. Conclusions: CERTAIN provides a reliable and valid method to evaluate resuscitation events in real time. CERTAIN provided the ability to complete data in real-time.

Information needs for the rapid response team electronic clinical tool

BackgroundInformation overload in healthcare is dangerous. It can lead to critical errors and delays. During Rapid Response Team (RRT) activations providers must make decisions quickly to rescue patients from physiological deterioration. In order to understand the clinical data required and how best to present that information in electronic systems we aimed to better assess the data needs of providers on the RRT when they respond to an event.MethodsA web based survey to evaluate clinical data requirements was created and distributed to all RRT providers at our institution. Participants were asked to rate the importance of each data item in guiding clinical decisions during a RRT event response.ResultsThere were 96 surveys completed (24.5% response rate) with fairly even distribution throughout all clinical roles on the RRT. Physiological data including heart rate, respiratory rate, and blood pressure were ranked by more than 80% of responders as being critical information. Resuscitation status was also considered critically useful by more than 85% of providers.ConclusionThere is a limited dataset that is considered important during an RRT. The data is widely available in EMR. The findings from this study could be used to improve user-centered EMR interfaces.

Evaluation of Data Utilization during Transfers of Critically Ill Patients between Hospitals

Background: There is little scientific data to guide inter-hospital transport of critically ill patients. This leads to practice variation with how providers communicate healthcare information between facilities and inappropriate communication can lead to significant patient harm. We analyzed data used by accepting providers during hospital transfer to form a rational protocol for information exchange. Methods: We conducted a prospective observational study of inter-hospital patient transfers to our medical intensive care unit (ICU). We recorded data that receiving clinicians requested, and whether that information was available upon admission. Following observation, we asked providers to complete a survey indicating whether a data point was useful for clinical decision making for the particular clinical case they had received. We analyzed the relative frequency of data requests and the discordance between available and requested data. Results: Twenty-five physician-patient interactions were observed with 45 surveys completed by critical care providers. On average, 13 data points were utilized for patients with perceived “mild” illness versus 18 data points for patients with “severe” illness. The most requested data were code status (19/25), blood culture status (19/25), and medications administered to the patient (16/25). Other data points identified as useful were past medical history, vital signs, white blood cell count, hemoglobin, lactate, pH, PaCO2 and chest x-ray findings with minimal variability depending on presumed diagnosis (respiratory failure, sepsis or other). Code status (7/19), arterial/venous blood gas (5/12), lactate (4/10), and medical power of attorney (3/5) were the most frequently unavailable data points when requested. Conclusion: Critical care providers use a small number of data points during the inter-hospital admission process, but many of these are frequently unavailable. A formal structured hand off tool is needed to improve information management during inter-hospital transfer. Such a tool must emphasize resuscitation status, critical labs, and ongoing interventions.