Jeroen Ludikhuize

Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score

BACKGROUND AND PURPOSE Clear and detectable signs of deterioration have been shown to be present in many patients multiple hours before undergoing a serious life-threatening event. To date, few studies are available describing normal practice and the possible effectiveness of structured tools regarding recognition of deteriorating patients. The aim of this study was to describe the current practice in measurement and documentation of vital signs and the possible usefulness of the Modified Early Warning Score (MEWS) to identify deteriorating patients on hospital wards. METHODS A retrospective observational study of medical and surgical patients from 2007 with a severe adverse event including cardiopulmonary arrest, unplanned intensive care unit admission, emergency surgery, or unexpected death was performed. We studied all vital parameters that were collected and documented in the 48 hours before these events, and the MEWS was retrospectively calculated. RESULTS Two hundred four patients were included. In the 48 hours before the event, a total of 2688 measurements of one or more vital signs were taken. Overall, 81% of the patients had an MEWS value of 3 or more at least once during the 48 hours before their event. Recordings of vital signs were mostly incomplete. Even when the MEWS was 3 or more, respiratory rate, diuresis, and oxygen saturation were documented in only 30% to 66% of assessments.

Outcomes Associated With the Nationwide Introduction of Rapid Response Systems in The Netherlands

Objective:To describe the effect of implementation of a rapid response system on the composite endpoint of cardiopulmonary arrest, unplanned ICU admission, or death. Design:Pragmatic prospective Dutch multicenter before-after trial, Cost and Outcomes analysis of Medical Emergency Teams trial. Setting:Twelve hospitals participated, each including two surgical and two nonsurgical wards between April 2009 and November 2011. The Modified Early Warning Score and Situation-Background-Assessment-Recommendation instruments were implemented over 7 months. The rapid response team was then implemented during the following 17 months. The effects of implementing the rapid response team were measured in the last 5 months of this period. Patients:All patients 18 years old and older admitted to the study wards were included. Measurements and Main Results:In total, 166,569 patients were included in the study representing 1,031,172 hospital admission days. No differences were observed in patient demographics between periods. The composite endpoint of cardiopulmonary arrest, unplanned ICU admission, or death per 1,000 admissions was significantly reduced in the rapid response team versus the before phase (adjusted odds ratio, 0.847; 95% CI, 0.725–0.989; p = 0.036). Cardiopulmonary arrests and in-hospital mortality were also significantly reduced (odds ratio, 0.607; 95% CI, 0.393–0.937; p = 0.018 and odds ratio, 0.802; 95% CI, 0.644–1.0; p = 0.05, respectively). Unplanned ICU admissions showed a declining trend (odds ratio, 0.878; 95% CI, 0.755–1.021; p = 0.092), whereas severity of illness at the moment of ICU admission was not different between periods. Conclusions:In this study, introduction of nationwide implementation of rapid response systems was associated with a decrease in the composite endpoint of cardiopulmonary arrests, unplanned ICU admissions, and mortality in patients in general hospital wards. These findings support the implementation of rapid response systems in hospitals to reduce severe adverse events.

Prognostic models for predicting mortality in elderly ICU patients: a systematic review

PurposeTo systematically review prognostic research literature on development and/or validation of mortality predictive models in elderly patients.MethodsWe searched the Scopus database until June 2010 for articles aimed at validating prognostic models for survival or mortality in elderly intensive care unit (ICU) patients. We assessed the models’ fitness for their intended purpose on the basis of barriers for use reported in the literature, using the following categories: (1) clinical credibility, (2) methodological quality (based on an existing quality assessment framework), (3) external validity, (4) model performance, and (5) clinical effectiveness.ResultsSeven studies were identified which met our inclusion criteria, one of which was an external validation study. In total, 17 models were found of which six were developed for the general adult ICU population and eleven specifically for elderly patients. Cohorts ranged from 148 to 12,993 patients and only smaller ones were obtained prospectively. The area under the receiver operating characteristic curve (AUC) was most commonly used to measure performance (range 0.71–0.88). The median number of criteria met for clinical credibility was 4.5 out of 7 (range 2.5–5.5) and 17 out of 20 for methodological quality (range 15–20).ConclusionsAlthough the models scored relatively well on methodological quality, none of them can be currently considered sufficiently credible or valid to be applicable in clinical practice for elderly patients. Future research should focus on external validation, addressing performance measures relevant for their intended use, and on clinical credibility including the incorporation of factors specific for the elderly population.

Clinical Relevance of Routinely Measured Vital Signs in Hospitalized Patients: A Systematic Review

BACKGROUND Conflicting evidence exists on the effectiveness of routinely measured vital signs on the early detection of increased probability of adverse events. PURPOSE To assess the clinical relevance of routinely measured vital signs in medically and surgically hospitalized patients through a systematic review. DATA SOURCES MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature, and Meta-analysen van diagnostisch onderzoek (in Dutch; MEDION) were searched to January 2013. STUDY SELECTION Prospective studies evaluating routine vital sign measurements of hospitalized patients, in relation to mortality, septic or circulatory shock, intensive care unit admission, bleeding, reoperation, or infection. DATA EXTRACTION Two reviewers independently assessed potential bias and extracted data to calculate likelihood ratios (LRs) and predictive values. DATA SYNTHESIS Fifteen studies were performed in medical (n = 7), surgical (n = 4), or combined patient populations (n = 4; totaling 42,565 participants). Only three studies were relatively free from potential bias. For temperature, the positive LR (LR+) ranged from 0 to 9.88 (median 1.78; n = 9 studies); heart rate 0.82 to 6.79 (median 1.51; n = 5 studies); blood pressure 0.72 to 4.7 (median 2.97; n = 4 studies); oxygen saturation 0.65 to 6.35 (median 1.74; n = 2 studies); and respiratory rate 1.27 to 1.89 (n = 3 studies). Overall, three studies reported area under the Receiver Operator Characteristic (ROC) curve (AUC) data, ranging from 0.59 to 0.76. Two studies reported on combined vital signs, in which one study found an LR+ of 47.0, but in the other the AUC was not influenced. CONCLUSIONS Some discriminative LR+ were found, suggesting the clinical relevance of routine vital sign measurements. However, the subject is poorly studied, and many studies have methodological flaws. Further rigorous research is needed specifically intended to investigate the clinical relevance of routinely measured vital signs. CLINICAL RELEVANCE The results of this research are important for clinical nurses to underpin daily routine practices and clinical decision making.

Characterizing Predictive Models of Mortality for Older Adults and Their Validation for Use in Clinical Practice

OBJECTIVES: To systematically identify and characterize prognostic models of mortality for older adults, their reported potential use, and the actual level of their (external) validity.

Rapid Response Systems in the Netherlands

Sixty-three (approximately 80%) of the 81 hospitals that responded to a survey sent to all hospitals in The Netherlands with nonpediatric intensive care units had a rapid response system (RRS) in place or were in the final process of starting one. Among many other findings regarding RRS infrastructure and implementation, only 38% of the hospitals allowed nurses to activate the rapid response team without physician consent.

How nurses and physicians judge their own quality of care for deteriorating patients on medical wards: Self-assessment of quality of care is suboptimal

Objective:To describe how nurses and physicians judge their own quality of care for deteriorating patients on medical wards compared with the judgment of independent experts. Design:Cross-sectional study using interviews of care-providers regarding their perceived quality of care for clinically deteriorating patients compared with retrospective judgment by independent experts. Setting:Academic Medical Center of Amsterdam, the Netherlands. Patients:Between April and July 2009, all patients with cardiopulmonary arrests and unplanned intensive care unit admissions from six medical nursing wards were included. The care-providers (nurses and physicians) taking care of these patients in the previous 12 hrs were included. Measurements and Main Results:Forty-seven events and 198 interviews were analyzed. Skill and knowledge level regarding the recognition of a deteriorating patient were rated on a scale of 1–10 with means (SD) of 7.9 (0.8) and 7.7 (0.9), respectively. Nurses and residents attributed coordination of care largely to themselves (74% and 76%, respectively). Communication, cooperation, and coordination were graded in a positive manner (medians between 7.3 and 8), whereas the medical staff graded these factors higher compared to the grading by nurses and residents. Negative predictive values regarding the presence of a delay compared with an expert panel was 37% for nurses and 38% for residents and specialists. Conclusions:Care-providers mostly rate their care provided to patients in the hours preceding a life-threatening adverse event as good. In contrast, independent experts had a more critical appraisal of the provided care in regards to timely recognition. These findings may partly explain the reluctance of care-providers to implement patient safety initiatives.