Epidemiology and outcome of medical emergency team calls within 48 hours of intensive care unit discharge.

BACKGROUND: Some patients experience early (within 48 h) clinical deterioration and medical emergency team (MET) review following intensive care unit (ICU) discharge. Few studies have explored early MET review, despite it being a recognised quality and safety indicator. AIMS: To evaluate the (i) proportion of patients discharged from ICU receiving MET review and timing of reviews; (ii) characteristics of patients who received early MET review and (iii) predictors of early MET review and associations with clinical outcomes. METHODS: This is a retrospective observational study of ICU discharges over 2 years in a tertiary hospital and involves descriptive and inferential statistics, including logistic regression analysis. RESULTS: Of 3712 patients, 312 (8.4%) had an early MET review. Patients with cardiothoracic, cardiovascular, gastrointestinal and general surgical diagnoses, higher illness severity or who received invasive ventilation had a higher risk of early MET review. On multivariable analysis, early MET review was associated with an increased risk of ICU re-admission (odds ratio (OR) 6.76, 95% confidence interval (CI) 5.01-9.13, P < 0.001), in-hospital mortality (OR 3.62, 95% CI 2.19-5.99, P < 0.001) and discharge to a nursing home (OR 2.49, 95% CI 1.25-4.97, P = 0.01). Length of stay was longer in patients requiring early post-ICU MET review compared to those who did not (median 16 days vs. 10 days, P < 0.001). CONCLUSIONS: One in 12 patients received post-ICU early MET review. This was more likely in patients who were invasively ventilated, had higher illness severity and had certain admission diagnoses. Such patients were at risk for worse outcomes. There is a need to identify reversible factors contributing to such increased risk.

Recommendations for clinical implementation of blood-based biomarkers for Alzheimer's disease.

Blood-based biomarkers (BBM) for Alzheimer's disease (AD) are being increasingly used in clinical practice to support an AD diagnosis. In contrast to traditional diagnostic modalities, such as amyloid positron emission tomography and cerebrospinal fluid biomarkers, BBMs offer a more accessible and lower cost alternative for AD biomarker testing. Their unique scalability addresses the anticipated surge in demand for biomarker testing with the emergence of disease-modifying treatments (DMTs) that require confirmation of amyloid pathology. To facilitate the uptake of BBMs in clinical practice, The Global CEO Initiative on Alzheimer's Disease convened a BBM Workgroup to provide recommendations for two clinical implementational pathways for BBMs: one for current use for triaging and another for future use to confirm amyloid pathology. These pathways provide a standardized diagnostic approach with guidance on interpreting BBM test results. Integrating BBMs into clinical practice will simplify the diagnostic process and facilitate timely access to DMTs for eligible patients.

Considerations for widespread implementation of blood-based biomarkers of Alzheimer's disease.

Diagnosing Alzheimer's disease (AD) poses significant challenges to health care, often resulting in delayed or inadequate patient care. The clinical integration of blood-based biomarkers (BBMs) for AD holds promise in enabling early detection of pathology and timely intervention. However, several critical considerations, such as the lack of consistent guidelines for assessing cognition, limited understanding of BBM test characteristics, insufficient evidence on BBM performance across diverse populations, and the ethical management of test results, must be addressed for widespread clinical implementation of BBMs in the United States. The Global CEO Initiative on Alzheimer's Disease BBM Workgroup convened to address these challenges and provide recommendations that underscore the importance of evidence-based guidelines, improved training for health-care professionals, patient empowerment through informed decision making, and the necessity of community-based studies to understand BBM performance in real-world populations. Multi-stakeholder engagement is essential to implement these recommendations and ensure credible guidance and education are accessible to all stakeholders.

Acknowledgement and use of advance care directives and goals of care by emergency department staff: a mixed method post intervention study.

INTRODUCTION: Advance Care Planning (ACP) refers to a process that includes Advance Care Directives (ACD) and Goals of Care (GOC), a practice widely used for over three decades. Following the findings of an audit and a cross-sectional study in 2019 and 2021 respectively, we implemented several educational and other interventional strategies aimed at enhancing staff awareness and emphasizing the importance of recognizing and documenting of ACD/GOC. The aim of this study was to evaluate the acknowledgement and use of ACD and GOC by Emergency Department (ED) staff following these interventions. METHOD: We used a mixed methods approach, incorporating both observational and cross-sectional designs with reflexive thematic analysis. Data extraction for the observational study took place between 1st April and 30th June 2023 focusing on a target population of randomly sampled adults aged ≥ 65 years. Demographics and other ACD and GOC related patients' clinical data were collected. Data collection for the cross-sectional study occurred between 19th July and 13th September 2023 targeting all ED staff. Information gathered included demographics, awareness about ACD and GOC, including storage location and implementation, as well as knowledge of Medical Treatment decision Makers (MTDM), a jurisdictional term identifying a person legally appointed to make healthcare decisions on behalf of someone who lacks decision-making capacity and other Victorian State legislative requirements were collected. RESULTS: In the observational period, 22,335 patients attended the ED and 19% (n = 6546) qualified for inclusion from which a sample of 308 patients were randomly extracted. We found ACD documents were noted in the medical records of 6.5% of the sample, fewer than 8% identified in our previous study. There was no correlation between ACD record availability and age (p = 0.054; CI ranging from - 0.065 to 7.768). The response rate for the cross-sectional survey was 12% (n = 340) in contrast to earlier study with 28% (n = 476) respondents. Staff knowledge and familiarity with ACD was 25% and GOC 45%. CONCLUSION: After implementing interventions in staff education and ACP awareness, we found that ACD documentation did not improve. However, GOC documentation increased in the context of heightened institutional awareness and integration into the Electronic Medical Records (EMR).

Long-term survival comparison of patients admitted to the intensive care unit following in-hospital cardiac arrest in perioperative and ward settings. A multicentre retrospective cohort study.

PURPOSE: Perioperative in-hospital cardiac arrests (Perioperative IHCAs) may have better outcomes than IHCAs in the ward (Ward IHCAs), due to enhanced monitoring and faster response. However, quantitative comparisons of their long-term outcomes are lacking, posing challenges for prognostication. METHODS: This retrospective multicentre study included adult intensive care unit (ICU) admissions from theatre/recovery or wards with a diagnosis of cardiac arrest between January 2018 and March 2022. We used data from 175 ICUs in the ANZICS adult patient database. The primary outcome was a survival time of up to 4 years. We used the Cox proportional hazards model adjusted for Sequential Organ Failure Assessment (SOFA) score, age, sex, comorbidities, hospital type, treatment limitation on admission to the ICU, and ICU treatments. Subgroup analyses examined age (≥ 65 years), intubation within the first 24 h, elective vs. emergency admission, and survival on discharge. RESULTS: Of 702,675 ICU admissions, 5,659 IHCAs were included (Perioperative IHCA 38%; Ward IHCA 62%). Perioperative IHCA group were younger, less frail, and less comorbid. Perioperative IHCA were most frequent in patients admitted to ICU after cardiovascular, gastrointestinal, or trauma surgeries. Perioperative IHCA group had longer 4-year survival (59.9% vs. 33.0%, p < 0.001) than the Ward IHCA group, even after adjustments (adjusted hazard ratio [HR]: 0.63, 95% confidence interval [CI] 0.57-0.69). This was concordant across all subgroups. Of note, older patients with Perioperative IHCA survived longer than both younger and older patients with Ward IHCA. CONCLUSION: Patients admitted to the ICU following Perioperative IHCA had longer survival than Ward IHCA. Future studies on IHCA should distinguish these patients.

Validating older adult patient's Medical Treatment Decision Maker's (MTDM). A retrospective observational study with follow-up phone interview transcript.

A Medical Treatment Decision Maker (MTDM), also referred to as surrogate decision maker, by law, is to be appointed to make medical treatment decisions on behalf of a person who cannot make such decisions for themselves. In the Emergency Department (ED) and acute healthcare services, the clinicians' (nurses and doctors) ability to contact MTDMs is essential for patient care, particularly in time-critical situations. Our primary objective was to review the verification process and assess the accuracy of MTDM contact numbers in the Health Information System (HIS) to assess compliance with legislation. We used a quantitative method with retrospective observational study design and follow-up phone interview transcript. One hundred and fifty-nine participants were randomly selected of whom 76 % had MTDM. Patient advancing age had statistically significant association with the number of call attempts made to reach the listed MTDM (P = 0.043; CI, -3.541 to -0.057) and the MTDM's consent to participate (p = 0.023).

Frequency and potential causes of non-beneficial Code Blue activations at a metropolitan teaching hospital.

BACKGROUND: Code Blue activations in patients who are not for resuscitation (NFR) may be regarded as non-beneficial and may cause harm to patients, relatives and hospital staff. AIMS: To estimate the prevalence of non-beneficial Code Blue calls in a metropolitan teaching hospital and identify modifiable factors that could be utilised to reduce these events. METHODS: The study consisted of two parts: (i) a retrospective analysis of all Code Blue activations over a 12-month period using prospectively collected data. Non-beneficial activations were defined as calls made in patients with a NFR order in either the current or any previous hospital admissions and (ii) an anonymous voluntary survey of staff who were present at a Code Blue activation. RESULTS: There were 186 Code Blue activations over the study period, with 48 (25.8%) defined as non-beneficial. Such patients had more comorbidities, previous hospitalisations and greater levels of frailty. Most non-beneficial calls occurred on general wards and more than three-quarters of patients had been reviewed by a consultant prior to the call. The survey determined that despite ward staff having a considerable degree of resuscitation experience, there were deficiencies in understanding of Code Blue criteria, the resuscitation status of patients under their care and the interpretation of goals of care. CONCLUSIONS: Over a quarter of Code Blue calls were deemed non-beneficial. Improving the visibility of NFR status and staff understanding of patient goals of care are needed, along with timely, proactive documentation of NFR status by experienced clinicians.

Acceptable performance of blood biomarker tests of amyloid pathology - recommendations from the Global CEO Initiative on Alzheimer's Disease.

Anti-amyloid treatments for early symptomatic Alzheimer disease have recently become clinically available in some countries, which has greatly increased the need for biomarker confirmation of amyloid pathology. Blood biomarker (BBM) tests for amyloid pathology are more acceptable, accessible and scalable than amyloid PET or cerebrospinal fluid (CSF) tests, but have highly variable levels of performance. The Global CEO Initiative on Alzheimer's Disease convened a BBM Workgroup to consider the minimum acceptable performance of BBM tests for clinical use. Amyloid PET status was identified as the reference standard. For use as a triaging test before subsequent confirmatory tests such as amyloid PET or CSF tests, the BBM Workgroup recommends that a BBM test has a sensitivity of ≥90% with a specificity of ≥85% in primary care and ≥75-85% in secondary care depending on the availability of follow-up testing. For use as a confirmatory test without follow-up tests, a BBM test should have performance equivalent to that of CSF tests - a sensitivity and specificity of ~90%. Importantly, the predictive values of all biomarker tests vary according to the pre-test probability of amyloid pathology and must be interpreted in the complete clinical context. Use of BBM tests that meet these performance standards could enable more people to receive an accurate and timely Alzheimer disease diagnosis and potentially benefit from new treatments.

Listen to me, I really am sick! Patient and family narratives of clinical deterioration before and during rapid response system intervention.

AIM: To explore patient and family narratives about their recognition and response to clinical deterioration and their interactions with clinicians prior to and during Medical Emergency Team (MET) activations in hospital. BACKGROUND: Research on clinical deterioration has mostly focused on clinicians' roles. Although patients and families can identify subtle cues of early deterioration, little research has focused on their experience of recognising, speaking up and communicating with clinicians during this period of instability. DESIGN: A narrative inquiry. METHODS: Using narrative interviewing techniques, 33 adult patients and 14 family members of patients, who had received a MET call, in one private and one public academic teaching hospital in Melbourne, Australia were interviewed. Narrative analysis was conducted on the data. RESULTS: The core story of help seeking for recognition and response by clinicians to patient deterioration yielded four subplots: (1) identifying deterioration, recognition that something was not right and different from earlier; (2) voicing concerns to their nurse or by family members on their behalf; (3) being heard, desiring a response acknowledging the legitimacy of their concerns; and (4) once concerns were expressed, there was an expectation of and trust in clinicians to act on the concerns and manage the situation. CONCLUSION: Clinical deterioration results in an additional burden for hospitalised patients and families to speak up, seek help and resolve their concerns. Educating patients and families on what to be concerned about and when to notify staff requires a close partnership with clinicians. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Clinicians must create an environment that enables patients and families to speak up. They must be alert to both subjective and objective information, to acknowledge and to act on the information accordingly. REPORTING METHOD: The consolidated criteria for reporting qualitative research (COREQ) guidelines were used for reporting. PATIENT OR PUBLIC CONTRIBUTION: The consumer researcher was involved in design, data analysis and publication preparation.

The impact of frailty on survival times up to one year among patients admitted to ICU with in-hospital cardiac arrest.

BACKGROUND: In-hospital cardiac arrest (IHCA) is a serious medical emergency. When IHCA occurs in patients with frailty, short-term survival is poor. However, the impact of frailty on long-term survival is unknown. METHODS: We performed a retrospective multicentre study of all critically ill adult (age ≥ 16 years) patients admitted to Australian intensive care units (ICU) between 1st January 2018 to 31st March 2022. We included all patients who had an IHCA within the 24 h before ICU admission with a documented Clinical Frail Scale (CFS). The primary outcome was median survival up to one year following ICU admission. The effect of frailty on one-year survival was assessed using a Cox proportional hazards model, adjusting for age, sex, comorbidities, sequential organ failure assessment (SOFA) score, and hospital type. RESULTS: We examined 3769 patients, of whom 30.8% (n = 1160) were frail (CFS ≥ 5). The median survival was significantly shorter for patients with frailty (median [IQR] days 19 [1-365] vs 302 [9-365]; p < 0.001). The overall one-year mortality was worse for the patients with frailty when compared to the non-frail group (64.8% [95%CI 61.9-67.5] vs 36.4% [95%CI 34.5-38.3], p < 0.001). Each unit increment in the CFS was associated with 22% worse survival outcome (adjusted Hazard ratio = 1.22, 95%-CI 1.19-1.26), after adjustment for confounders. The survival trend was similar among patients who survived the hospitalization. CONCLUSION: In this retrospective multicentre study, frailty was associated with poorer one-year survival in patients admitted to Australian ICUs following an IHCA.

Use of point-of-care ultrasound during cardiac arrest in the intensive care unit: A cross-sectional survey.

BACKGROUND: There is growing interest in the use of point-of-care ultrasound during cardiac arrest, but few studies document its use in the intensive care unit. OBJECTIVE: We hypothesised this may reflect a low prevalence of use of point-of-care ultrasound during cardiac arrest or negative attitudes towards its use. We aimed to determine the self-reported prevalence, attitudes towards, and barriers to use of point-of-care ultrasound during cardiac arrest in the intensive care unit. METHODS: We conducted a web-based survey over 3 months (08/08/2022-06/11/2022), of intensive care unit consultants and registrars in Victoria, Australia. Descriptive and mixed-methods analyses of Likert-type and free-text answers were performed. RESULTS: The response rate was 91/398 (22.8%), split evenly between consultants and registrars. There was a broad range of clinical and ultrasound experience. Only 22.4% (22/91) of respondents reported using point-of-care ultrasound 75-100% of the time during their management of cardiac arrest. Respondents rated the value they place in point-of-care ultrasound during cardiac arrest 3 (interquartile range: 3-4) and that of a "skilled operator" 4 ((interquartile range; 4-5) on a 5-point scale. Free-text analysis suggested exclusion of "tamponade" (40/80 [50%] comments) as the most valuable use-case and "skill" as a personal barrier (20/73 [27.4%] comments). Personal and departmental barriers were not rated highly, although registrars perceived "lack of a structured training program" as a barrier. Respondents were equivocal in the value they gave point-of-care ultrasound during cardiac arrest but saw greater value when conducted by a skilled operator. CONCLUSIONS: Point-of-care ultrasound was reported to be infrequently used in cardiac arrest, mostly due to self-perceived skill and lack of a structured training program.

Improving the pre-medical emergency team: the case for a behavioural theoretical lens.

There is mounting evidence that the pre-medical emergency team (pre-MET) of rapid response systems is underutilised in clinical practice due to suboptimal structures and processes and resource constraints. In this perspective article, we argue for examining the pre-MET through a 'Behaviour Change Wheel' lens to improve the pre-MET and maximise the associated patient safety benefits. Using pre-MET communication practices as an example, we illustrate the value of the COM-B model, where clinicians' 'capability', 'opportunity', and 'motivation' drive 'behaviour'. Optimising clinicians' behaviours and establishing failsafe rapid response systems is a complex undertaking; however, examining clinicians' behaviours through the COM-B model enables reframing barriers and facilitators to develop multifaceted and coordinated solutions that are behaviourally and theoretically based. The COM-B model is recommended to clinical governance leaders and health services researchers to explore the underlying causes of behaviour and successfully enact change in the design, implementation, and use of the pre-MET to improve patient safety.

Infectious and sepsis presentations to, and hospital admissions from emergency departments in Victoria, Australia.

OBJECTIVE: To investigate the frequency and outcomes of adult infectious and sepsis presentations to, and hospital admissions from, Emergency Departments (EDs) in Victoria, Australia. METHODS: Retrospective cohort study using the Victorian Emergency Minimum Dataset and Victorian Admitted Episodes Dataset. We included adults (age ≥ 18 years) presenting to an ED, or admitted to hospital from ED in Victoria between July 2017 and June 2018. One-year mortality was analysed until June 2019 using the Victorian Death Index, and ICD-10 coding was used to identify cases. RESULTS: Among 1.28 million ED presentations over 1 year, 12.00% and 0.45% were coded with infectious and sepsis diagnoses, respectively. Despite having lower triage categories, patients with infections were more likely to be admitted to hospital (50.4% vs 44.9%), but not directly to ICU (0.8%). Patients coded with sepsis were assigned higher triage categories and required hospital admission much more frequently (96.4% vs 44.9%), including to ICU (15.9% vs 0.8%). Patients presenting with infections and sepsis had increased risk of 1-year mortality (adjusted hazard ratio 1.44 and 4.13, respectively). Of the 648 280 hospital admissions from the ED, infection and sepsis were coded in 23.69% and 2.66%, respectively, and the adjusted odds ratio for 1-year mortality were 1.64 and 4.79, respectively. CONCLUSIONS: Infections and sepsis are common causes of presentation to, and admission from the ED in Victoria. Such patients experience higher mortality than non-infectious patients, even after adjusting for age. There is a need to identify modifiable factors contributing to these outcomes.

Examining emergency departments practices on advance care directives and medical treatment decision making using the victorian emergency minimum dataset.

INTRODUCTION: Existence of Advance Care Planning (ACP) documents including contact details of Medical Treatment Decision Makers (MTDM), are essential patient care records that support Emergency Department (ED) clinicians in implementing treatment concordant with patients' expressed wishes. Based upon previous findings, we conducted a statewide study to evaluate the performance of Victorian public hospital emergency departments on reporting of availability of records for ACP. METHOD: The study is a quantitative retrospective observational comparative design based upon ED tier levels as defined by the Australasian College for Emergency Medicine (ACEM) for the calendar year 2021. RESULTS: Of 1.8 million total Victorian ED attendances, 15,222 patients had an ACP alert status recorded. Of these, 7296 were aged ≥ 65 years (study group). Of the thirty-one public EDs that submitted data, 65 % were accredited and assigned a level of service tier. The presence of ACP alerts positively correlated to location, tier level, age and gender (MANOVA wilk's; p < 0.001, value=.981, F = (12, 15,300), partial ƞ2 = .006, observed power = 1.0 = 95.919). CONCLUSION: The identified rate of ACP reporting is low. Strategies to improve the result include synchronising ACP (generated at different points) electronically, staff education, training and further validation of the data at the sending and receiving agencies.

Dose equivalence for metaraminol and noradrenaline - A retrospective analysis.

BACKGROUND: Noradrenaline and metaraminol are commonly used vasopressors in critically ill patients. However, little is known of their dose equivalence. METHODS: We conducted a single centre retrospective cohort study of all ICU patients who transitioned from metaraminol to noradrenaline infusions between August 26, 2016 and December 31, 2020. Patients receiving additional vasoactive drug infusion were excluded. Dose equivalence was calculated based on the last hour metaraminol dose (in µg/min) and the first hour noradrenaline dose (in µg/min) with the closest matched mean arterial pressure (MAP). Sensitivity analyses were performed on patients with acute kidney injury (AKI), sepsis and mechanical ventilation. RESULTS: We studied 195 patients. The median conversion ratio of metaraminol to noradrenaline was 12.5:1 (IQR 7.5-20.0) for the overall cohort. However, the coefficient of variation was 77% and standard deviation was 11.8. Conversion ratios were unaffected by sepsis or mechanical ventilation but increased (14:1) with AKI. One in five patients had a MAP decrease of >10 mmHg during the transition period from metaraminol to noradrenaline. Post-transition noradrenaline dose (p < 0.001) and AKI (p = 0.045) were independently associated with metaraminol dose. The proportion of variation in noradrenaline dose predicted from metaraminol dose was low (R2 = 0.545). CONCLUSIONS: The median dose equivalence for metaraminol and noradrenaline in this study was 12.5:1. However, there was significant variance in dose equivalence, only half the proportion of variation in noradrenaline infusion dose was predicted by metaraminol dose, and conversion-associated hypotension was common.

Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Executive Summary: Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS). CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Frequency of and associations with alterations of medical emergency team calling criteria in a teaching hospital emergency department.

BACKGROUND: Medical emergency team (METs), activated by vital sign-based calling criteria respond to deteriorating patients in the hospital setting. Calling criteria may be altered where clinicians feel this is appropriate. Altered calling criteria (ACC) has not previously been evaluated in the emergency department (ED) setting. OBJECTIVES: The objectives of this study were to (i) describe the frequency of ACC in a teaching hospital ED and the number and type of vital signs that were modified and (ii) associations between ACC in the ED and differences in the baseline patient characteristics and adverse outcomes including subsequent MET activations, unplanned intensive care unit (ICU) admissions and death within 72 h of admission. METHODS: Retrospective observational study of patients presenting to an academic, tertiary hospital ED in Melbourne, Australia between January 1st, 2019 and December 31st, 2019. The primary outcome was frequency and nature of ACC in the ED. Secondary outcomes included differences in baseline patient characteristics, frequency of MET activation, unplanned ICU admission, and mortality in the first 72 h of admission between those with and without ACC in the ED. RESULTS: Amongst 14 159 ED admissions, 725 (5.1%) had ACC, most frequently for increased heart or respiratory rate. ACC was associated with older age and increased comorbidity. Such patients had a higher adjusted risk of MET activation (odds ratio [OR]: 3.14, 95% confidence interval [CI]: 2.50-3.91, p = <0.001), unplanned ICU admission (OR: 1.97, 95% CI: 1.17-3.14, p = 0.016), and death (OR: 3.87, 95% CI: 2.08-6.70, p = 0.020) within 72 h. CONCLUSIONS: ACC occurs commonly in the ED, most frequently for elevated heart and respiratory rates and is associated with worse patient outcomes. In some cases, ACC requires consultant involvement, more frequent vital sign monitoring, expeditious inpatient team review, or ICU referral.

Haemodynamic changes during prone versus supine position in patients with COVID-19 acute respiratory distress syndrome.

BACKGROUND: Prone positioning improves oxygenation in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19. However, its haemodynamic effects are poorly understood. OBJECTIVES: The objective of this study was to investigate the acute haemodynamic changes associated with prone position in mechanically ventilated patients with COVID-19 ARDS. The primary objective was to describe changes in cardiac index with prone position. The secondary objectives were to describe changes in mean arterial pressure, FiO2, PaO2/FiO2 ratio, and oxygen delivery (DO2) with prone position. METHODS: We performed this cohort-embedded study in an Australian intensive care unit, between September and November 2021. We included adult patients with severe COVID-19 ARDS, requiring mechanical ventilation and prone positioning for respiratory failure. We placed patients in the prone position for 16 h per session. Using pulse contour technology, we collected haemodynamic data every 5 min for 2 h in the supine position and for 2 h in the prone position consecutively. RESULTS: We studied 18 patients. Cardiac index, stroke volume index, and mean arterial pressure increased significantly in the prone position compared to supine position. The mean cardiac index was higher in the prone group than in the supine group by 0.44 L/min/m2 (95% confidence interval, 0.24 to 0.63) (P < 0.001). FiO2 requirement decreased significantly in the prone position (P < 0.001), with a significant increase in PaO2/FiO2 ratio (P < 0.001). DO2 also increased significantly in the prone position, from a median DO2 of 597 mls O2/min (interquartile range, 504 to 931) in the supine position to 743 mls O2/min (interquartile range, 604 to 1075) in the prone position (P < 0.001). CONCLUSION: Prone position increased the cardiac index, mean arterial pressure, and DO2 in invasively ventilated patients with COVID-19 ARDS. These changes may contribute to improved tissue oxygenation and improved outcomes observed in trials of prone positioning.

Improving the management of medical emergency team calls due to suspected infections: A before-after study.

Objective: To introduce a management guideline for sepsis-related MET calls to increase lactate and blood culture acquisition, as well as prescription of appropriate antibiotics. Design: Prospective before (Jun-Aug 2018) and after (Oct-Dec 2018) study was designed. Setting: A public university linked hospital in Melbourne, Australia. Participants: Adult patients with MET calls related to sepsis/infection were included. Main outcome measures: The primary outcome measure was the proportion of MET calls during which both a blood culture and lactate level were ordered. Secondary outcomes included the frequency with which new antimicrobials were commenced by the MET, and the presence and class of administered antimicrobials. Results: There were 985 and 955 MET calls in the baseline and after periods, respectively. Patient features, MET triggers, limitations of treatment and disposition after the MET call were similar in both groups. Compliance with the acquisition of lactates (p = 0.101), respectively. There was a slight reduction in compliance with lactate acquisition in the after period (97% vs 99%; p = 0.06). In contrast, there was a significant increase in acquisition of blood cultures in the after period (69% vs 78%; p = 0.035). Conclusions: Introducing a sepsis management guideline and enhanced linkage with an AMS program increased blood culture acquisition and decreased broad spectrum antimicrobial use but didn't change in-hospital mortality.