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.

Can acutely ill patients predict their outcomes? A scoping review.

INTRODUCTION: The full impact of an acute illness on subsequent health is seldom explicitly discussed with patients. Patients' estimates of their likely prognosis have been explored in chronic care settings and can contribute to the improvement of clinical outcomes and patient satisfaction. This scoping review aimed to identify studies of acutely ill patients' estimates of their outcomes and potential benefits for their care. METHODS: A search was conducted in PubMed, Embase, Web of Science and Google Scholar, using terms related to prognostication and acute care. After removal of duplicates, all articles were assessed for relevance by six investigator pairs; disagreements were resolved by a third investigator. Risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: Our search identified 3265 articles, of which 10 were included. The methods of assessing self-prognostication were very heterogeneous. Patients seem to be able to predict their need for hospital admission in certain settings, but not their length of stay. The severity of their symptoms and the burden of their disease are often overestimated or underestimated by patients. Patients with severe health conditions and their relatives tend to be overoptimistic about the likely outcome. CONCLUSION: The understanding of acutely ill patients of their likely outcomes and benefits of treatment has not been adequately studied and is a major knowledge gap. Limited published literature suggests patients may be able to predict their need for hospital admission. Illness perception may influence help-seeking behaviour, speed of recovery and subsequent quality of life. Knowledge of patients' self-prognosis may enhance communication between patients and their physicians, which improves patient-centred care.

Using Vital Signs to Place Acutely Ill Patients Quickly and Easily into Clinically Helpful Pathophysiologic Categories: Derivation and Validation of Eight Pathophysiologic Categories in Two Distinct Patient Populations of Acutely Ill Patients.

BACKGROUND: Early warning scores reliably identify patients at risk of imminent death, but do not provide insight into what may be wrong with the patient or what to do about it. OBJECTIVE: Our aim was to explore whether the Shock Index (SI), pulse pressure (PP), and ROX Index can place acutely ill medical patients in pathophysiologic categories that could indicate the interventions required. METHODS: A retrospective post-hoc analysis of previously obtained and reported clinical data for 45,784 acutely ill medical patients admitted to a major regional referral Canadian hospital between 2005 and 2010 and validated on 107,546 emergency admissions to four Dutch hospitals between 2017 and 2022. RESULTS: SI, PP, and ROX values divided patients into eight mutually exclusive physiologic categories. Mortality was highest in patient categories that included ROX Index value < 22, and a ROX Index value < 22 multiplied the risk of any other abnormality. Patients with a ROX Index value < 22, PP < 42 mm Hg, and SI > 0.7 had the highest mortality and accounted for 40% of deaths within 24 h of admission, whereas patients with a PP ≥ 42 mm Hg, SI ≤ 0.7, and ROX Index value ≥ 22 had the lowest risk of death. These results were the same in both the Canadian and Dutch patient cohorts. CONCLUSIONS: SI, PP, and ROX Index values can place acutely ill medical patients into eight mutually exclusive pathophysiologic categories with different mortality rates. Future studies will assess the interventions needed by these categories and their value in guiding treatment and disposition decisions.

Validation of a Simple Score for Mortality Prediction in a Cohort of Unselected Emergency Patients.

Background: Prognostication is an important component of medical decision-making. A patients' general prognosis can be difficult to measure. The Simple Prognostic Score (SPS) was designed to include patients' age, mobility, aggregated vital signs, and the treating physician's decision to admit to aid prognostication. Study Aim. Our study aim is to validate the SPS, compare it with the Emergency Severity Index (ESI) regarding its prognostic performance, and test the interrater reliability of the subjective variable of the decision to admit. Methods: Over a period of 9 weeks all patients presenting to the ED were included, routinely interviewed, final disposition registered, and followed up for one year. The C-statistics of discrimination was used to compare SPS and ESI predictions of 7-day, 30-day, and 1-year mortality. Youden J Statistics and Odds ratio, using logistical regression, were calculated for the Simple Prognostic Score. In a subset, a chart review was performed by senior physicians for a secondary assessment of the decision to admit. Interrater reliability was calculated using percentages and Cohens Kappa. Results: Out of 5648 patients, 3272 (57.9%) had a low SPS (i.e., ≤ 1); none of these patients died within 7 days, 2 (0.1%) died within 30 days after presentation and 19 (0.6%) died within a year. The area under the curve for 1-year mortality of the Simple Prognostic Score was 0.848. Secondary analysis of the interrater agreement for the decision to admit was 92%. Conclusion: In a prospective study of unselected ED patients, the Simple Prognostic Score was validated as a reliable predictor of short- and long-term mortality.

Understanding what matters most to patients in acute care in seven countries, using the flash mob study design.

BACKGROUND: Truly patient-centred care needs to be aligned with what patients consider important, and is highly desirable in the first 24 h of an acute admission, as many decisions are made during this period. However, there is limited knowledge on what matters most to patients in this phase of their hospital stay. The objective of this study was to identify what mattered most to patients in acute care and to assess the patient perspective as to whether their treating doctors were aware of this. METHODS: This was a large-scale, qualitative, flash mob study, conducted simultaneously in sixty-six hospitals in seven countries, starting November 14th 2018, ending 50 h later. One thousand eight hundred fifty adults in the first 24 h of an acute medical admission were interviewed on what mattered most to them, why this mattered and whether they felt the treating doctor was aware of this. RESULTS: The most reported answers to "what matters most (and why)?" were 'getting better or being in good health' (why: to be with family/friends or pick-up life again), 'getting home' (why: more comfortable at home or to take care of someone) and 'having a diagnosis' (why: to feel less anxious or insecure). Of all patients, 51.9% felt the treating doctor did not know what mattered most to them. CONCLUSIONS: The priorities for acutely admitted patients were ostensibly disease- and care-oriented and thus in line with the hospitals' own priorities. However, answers to why these were important were diverse, more personal, and often related to psychological well-being and relations. A large group of patients felt their treating doctor did not know what mattered most to them. Explicitly asking patients what is important and why, could help healthcare professionals to get to know the person behind the patient, which is essential in delivering patient-centred care. TRIAL REGISTRATION: NTR (Netherlands Trial Register) NTR7538 .

A simple prognostic score predicts one-year mortality of alert and calm emergency department patients: A prospective two-center observational study.

STUDY OBJECTIVE: To derive and validate a prognostic score to predict 1-year mortality using vital signs, mobility and other variables that are readily available at the bedside at no additional cost. METHODS: Post hoc analysis of two independent prospective observational studies in two emergency departments, one in Denmark and the other in Switzerland. PARTICIPANTS: Alert and calm emergency department patients. MEASUREMENTS: The prediction of mortality from presentation to 365 days by vital signs, mobility and other variables that are readily available at the bedside at no additional cost. RESULTS: One thousand six hundred and eighteen alert and calm patients were in the Danish cohort and 1331 in the Swiss cohort. Logistic regression identified age >68 years, abnormal vital signs, impaired mobility and the decision to admit as significant predictors of 365-day mortality. A simple prognostic score awarded one point to each of these predictors. Less than two of these predictors were present in 45.6% of patients, and only 0.4% of these patients died within a year. If two or more of these predictors were present, 365-day mortality increased exponentially. CONCLUSION: Age >68 years, the decision for hospital admission, any vital sign abnormality at presentation and impaired mobility at presentation are equally powerful predictors of 1-year mortality in alert and calm emergency department patients. If validated by others these predictors could be used to discharge patients with confidence since nearly half of these patients had less than two predictors and none of them died within 30 days. However, when two or more predictors were present 365-day mortality increased exponentially.

Truth disclosure on prognosis: Is it ethical not to communicate personalised risk of death?

Predicting risk of death based on personalised and objective clinical indicators is an improvement over intuition and clinical judgement. Risk assessment can benefit clinicians by improving prognostic certainty, and truth disclosure helps patients and families by preventing futile management. Some argue that consent should be obtained before a patient is given an estimate of their prognosis as disclosure of bad news can overburden patients. In this article, we argue that it is unethical not to use existing person-specific information to guide diagnosis and shared decision making on management in partnership with well-informed patients. Disclosure of a poor prognosis should be normalised in personalised medicine, performed incrementally and with sensitivity so that it is acceptable to patients, and only occur if patients want to know it. However, a requirement of consent for truth disclosure should not be mandatory. Despite some level of imprecision, personalised risk estimations can be used to tailor management to the patient's informed wishes and ensure that healthcare providers and families are acting ethically in the patient's best interest.

Crisis checklists for in-hospital emergencies: expert consensus, simulation testing and recommendations for a template determined by a multi-institutional and multi-disciplinary learning collaborative.

BACKGROUND: 'Failure to rescue' of hospitalized patients with deteriorating physiology on general wards is caused by a complex array of organisational, technical and cultural failures including a lack of standardized team and individual expected responses and actions. The aim of this study using a learning collaborative method was to develop consensus recomendations on the utility and effectiveness of checklists as training and operational tools to assist in improving the skills of general ward staff on the effective rescue of patients with abnormal physiology. METHODS: A scoping study of the literature was followed by a multi-institutional and multi-disciplinary international learning collaborative. We sought to achieve a consensus on procedures and clinical simulation technology to determine the requirements, develop and test a safe using a checklist template that is rapidly accessible to assist in emergency management of common events for general ward use. RESULTS: Safety considerations about deteriorating patients were agreed upon and summarized. A consensus was achieved among an international group of experts on currently available checklist formats performing poorly in simulation testing as first responders in general ward clinical crises. The Crisis Checklist Collaborative ratified a consensus template for a general ward checklist that provides a list of issues for first responders to address (i.e. 'Check In'), a list of prompts regarding common omissions (i.e. 'Stop & Think'), and, a list of items required for the safe "handover" of patients that remain on the general ward (i.e. 'Check Out'). Simulation usability assessment of the template demonstrated feasibility for clinical management of deteriorating patients. CONCLUSIONS: Emergency checklists custom-designed for general ward patients have the potential to guide the treatment speed and reliability of responses for emergency management of patients with abnormal physiology while minimizing the risk of adverse events. Interventional trials are needed.

Hospital Readmissions - Independent Predictors of 30-day Readmissions derived from a 10 year Database.

Unplanned medical 30 day readmissions place a burden on the provision of acute hospital services and are increasingly used as quality indicators to assess quality of care in hospitals. Multivariable logistic regression of a 10 year database showed that four factors were most strongly associated with early readmission: Charlson comorbidity index >=1, respiratory disease as a principal diagnosis, liver disease and alcohol-related illness as an additional diagnosis, and the number of previous readmissions. Disease and patient-related factors beyond control of the hospital are the factors most strongly associated with 30 day readmission to hospital, suggesting that this may not be an appropriate quality indicator.

Curcumin supplementation likely attenuates delayed onset muscle soreness (DOMS).

INTRODUCTION: Oral curcumin decreases inflammatory cytokines and increases muscle regeneration in mice. PURPOSE: To determine effects of curcumin on muscle damage, inflammation and delayed onset muscle soreness (DOMS) in humans. METHOD: Seventeen men completed a double-blind randomized-controlled crossover trial to estimate the effects of oral curcumin supplementation (2.5 g twice daily) versus placebo on single-leg jump performance and DOMS following unaccustomed heavy eccentric exercise. Curcumin or placebo was taken 2 d before to 3 d after eccentric single-leg press exercise, separated by 14-d washout. Measurements were made at baseline, and 0, 24 and 48-h post-exercise comprising: (a) limb pain (1-10 cm visual analogue scale; VAS), (b) muscle swelling, (c) single-leg jump height, and (d) serum markers of muscle damage and inflammation. Standardized magnitude-based inference was used to define outcomes. RESULTS: At 24 and 48-h post-exercise, curcumin caused moderate-large reductions in pain during single-leg squat (VAS scale -1.4 to -1.7; 90 %CL: ±1.0), gluteal stretch (-1.0 to -1.9; ±0.9), squat jump (-1.5 to -1.1; ± 1.2) and small reductions in creatine kinase activity (-22-29 %; ±21-22 %). Associated with the pain reduction was a small increase in single-leg jump performance (15 %; 90 %CL ± 12 %). Curcumin increased interleukin-6 concentrations at 0-h (31 %; ±29 %) and 48-h (32 %; ±29 %) relative to baseline, but decreased IL-6 at 24-h relative to post-exercise (-20 %; ±18 %). CONCLUSIONS: Oral curcumin likely reduces pain associated with DOMS with some evidence for enhanced recovery of muscle performance. Further study is required on mechanisms and translational effects on sport or vocational performance.

The prediction of death up to 100 days after admission to hospital for acute medical illness - the comparison of two ECG interpretation methods with ECG-dispersion mapping.

BACKGROUND: the prognostic performances of different ECG interpretation methods have not been compared. METHODS: the 100 day mortality of 513 patients predicted by Marquette proprietary ECG software, Tan et al's scoring system and the myocardial micro-alternation index (MMI) were compared. RESULTS: 33 patients (6.4%) died within 100 days of hospital admission. The c statistics for Marquette and Tan ECG interpretation and MMI were not statistically different (i.e. 0.64, 0.68 and 0.73, respectively). Only MMI was independent from age as a predictor of mortality. The c statistic for MMI plus age of 0.81 was significantly higher than that of Marquette ECG interpretation (p 0.015). CONCLUSION: predictions of 100 day mortality by of all three ECG interpretation methods are equivalent.

PRISMA Analysis of 30 Day Readmissions to a Tertiary Cancer Hospital.

BACKGROUND: Hospital readmissions are increasingly used as a quality indicator. Patients with cancer have an increased risk of readmission. The purpose of this study was to develop an in depth understanding of the causes of readmissions in patients undergoing cancer treatment using PRISMA methodology and was subsequently used to identify any potentially preventable causes of readmission in this cohort. METHODS: 50 consecutive 30 day readmissions from the 1st November 2014 to the medical admissions unit (MAU) at a specialist tertiary cancer hospital in the Northwest of England were analysed retrospectively. RESULTS: Q25(50%) of the patients were male with a median age of 59 years (range 19-81). PRISMA analysis showed that active (human) factors contributed to the readmission of 4 (8%) of the readmissions, which may have been potentially preventable. All of the readmissions were driven by a medical condition related to the patient's underlying cancer and ongoing cancer treatment. CONCLUSIONS: The majority of readmissions of patients undergoing cancer treatment appear to be related to the underlying condition and, as such, are predictable but not preventable. This suggests that hospital readmission is not a good quality indicator in this cohort of patients.

How to follow the NEWS.

BACKGROUND: it is not known how best to respond to changes in the National Early Warning Score (NEWS) after hospital admission. This report manipulates and extrapolates previously published data on the trajectories of the abbreviated early warning score (AbEWS i.e. NEWS that does not include mental status). METHODS: trajectories of averaged AbEWS for patients for their first 5 days in hospital and their last 5 days in hospital were combined to obtain an approximation of what happens to the average patient while in hospital. RESULTS: the trajectories of patients admitted with a low score are different from those admitted with a high score. Patients should be observed for 12 to 24 hours before their outcome can be predicted. The score of most patients who die in hospital trends upward on the second or third day after admission. Patients admitted with a score of 0-2 who raise their score to >=3 have a ten-fold increase in-hospital mortality. CONCLUSIONS: the trajectories of early warning scores after admission are of prognostic importance, and escalation protocols should relate changes in the score to its initial value on admission.

Implementation of a fast triage score for patients arriving to a low resource hospital in Uganda.

Background: The Kitovu Fast Triage (KFT) score predicts imminent mortality from mental status, gait and either respiratory rate or oxygen status. As some non-life-threatening conditions require immediate attention, the South African Triage System (SATS) assigns arbitrary rankings of urgency for specific patient presentations. Aim: Establish the feasibility of determining and then comparing the KFT score and explicitly defined SATS urgency rankings. Methods: A computerized proforma used standardized methods of assessing and measuring mental status and gait, and respiratory rate and collected explicitly defined clinical presentations and SATS urgency rankings on 4,842 patients at the time of their arrival to the hospital. Results: 75 % of patients were awake and able to count the months backwards from December to September. Respiratory rates measured by a computer application had no clustering of values or digit preference; however, oximetry failed in 14 % of patients, making the score based on respiratory rate the most practical in our setting. Determining the SATS acuity ranking and both KFT scores usually took <90 s; the commonest complaints were pain, dyspnoea, and fever, which often occurred together; overall 3574 (73.8 %) patients had at least one of these symptoms as did 96.4 % of those with the highest KFT score based on respiratory rate. 12 % of patients with the lowest KFT score based on respiratory rate had one or more very urgent SATS rankings, 52 % of whom had non-severe chest pain. Only 5.7 % of patients complaining of fever had a temperature >38 °C. Conclusion: Whilst the KFT score based on respiratory rate could be rapidly determined in all patients, it identified some patients as low acuity who had very urgent SATS rankings. However, most of these patients had non-severe chest pain, which may not be a very urgent presentation in our setting as ischaemic heart disease remains uncommon in sub-Saharan Africa.

The optimal duration of continuous respiratory rate monitoring to predict in-hospital mortality within seven days of admission - A pilot study in a low resource setting.

Background: Currently there are no established benefits from the continuous monitoring of vital signs, and the optimal time period for respiratory rate measurement is unknown. Setting: Low resource Ugandan hospital. Methods: Prospective observational study. Respiratory rates of acutely ill patients were continuously measured by a piezoelectric device for up to seven hours after admission to hospital. Results: 22 (5.5%) out of 402 patients died within 7 days of hospital admission. The highest c-statistic of discrimination for 7-day mortality (0.737 SE 0.078) was obtained after four hours of continuously measured respiratory rates transformed into a weighted respiratory rate score (wRRS). After seven hours of measurement the c-statistic of the wRRS fell to 0.535 SE 0.078. 20% the patients who died within seven days did not have an elevated National Early Warning Score (NEWS) on admission but were identified by the 4-hour wRRS. None of the 88 patients whose average respiratory rate remained between 12 and 20 bpm throughout four hours of observation died within 7 days of admission. A simple predictive model that included the four-hour wRRS, Shock Index and altered mental status had a c-statistic for 7-day in-hospital mortality of 0.843 SE. 0.057. Conclusion: Four hours of continuously measured respiratory rates was the observation period that best predicted 7-day in-hospital mortality. After four hours the discrimination of a weighted respiratory rate score deteriorated rapidly.

Predictive value and interrater reliability of mental status and mobility assessment in the emergency department.

AIM: To investigate the predictive value of both mental status, assessed with the AVPUC (Alert, responds to Voice, responds to Pain, Unresponsive, and new Confusion) scale, and mobility assessments, and their interrater reliability (IRR) between triage clinicians and a research team. METHOD: Prospective study of consecutive patients who presented to an ED. Mental status and mobility were assessed by triage clinicians and by a dedicated research team. RESULTS: 4,191 patients were included. After adjustment for age and sex, patients with altered mental status have an odds ratio of 6.55 [4.09-10.24] to be admitted in the ICU and an odds ratio of 21.16 [12.06-37.01] to die within 30 days; patients with impaired mobility have an odds ratio of 7.08 [4.60-11.12] to be admitted in the ICU and an odds ratio of 12.87 [5.93-32.30] to die within 30 days. The kappa coefficient between triage clinicians and the research team for mental status assessment was 0.75, and 0.80 for mobility. CONCLUSION: Assessment of mental status by the AVPUC scale, and mobility by a simple dichotomous scale are suitable for ED triage. Both altered mental status and impaired mobility are associated with adverse outcomes. Mental status and mobility assessment have good interrater reliability.