Frailty is associated with reduced prospect of discharge home after in-hospital cardiac arrest.

BACKGROUND: Frailty is common among acute hospital patients and might adversely affect recovery from inpatient cardiac arrest. AIM: To assess the relationship between hospital admission characteristics, including frailty, and discharge outcome after in-hospital cardiac arrest. METHODS: Prospectively collected data were retrospectively analysed for all separations from a tertiary hospital during 2008-2017 that involved rapid response team attendance for cardiac arrest. Hospital Frailty Risk Score (HFRS) and Charlson index of comorbidity were calculated from 'primary' and 'associated' International Classification of Diseases, 10th revision, Australian Modification diagnoses. HFRS ≥5 was taken to signify frailty. Discharge home from hospital and death in hospital were modelled using logistic regression. RESULTS: There were 388 in-hospital arrest patients: 91% were aged ≥50 years, 34% were previously discharged in the past 6 months, 66% were unplanned admissions, 63% were non-cardiology-cardiothoracic admissions, 45% had a Charlson comorbidity index ≥2 and 19% were identified as frail. Discharge home occurred in 22%, discharge to another hospital 17% and death 62%. Of the frail patients, only 3 (4%) were discharged home, 12 (17%) were discharged to another hospital and 57 (79%) died in hospital. Fewer frail patients were discharged home compared with non-frail patients (4 vs 26%; odds ratio (OR) 0.13, P = 0.001). On multivariable analysis, patients were less likely to be discharged home if they had frailty (OR 0.24, P = 0.02), age ≥ 50 years (OR 0.36, P = 0.01), non-cardiology-cardiothoracic unit admission (OR 0.40, P = 0.001) and unplanned admission (OR 0.57, P = 0.04). Frail patients discharged to another hospital spent a median of 15 days (interquartile range 11-23) in the hospital post-arrest before leaving to continue inpatient care elsewhere. Frailty was associated with death in hospital on univariate analysis (79 vs 58%; OR 2.80, P = 0.001) but not after controlling for other factors. CONCLUSION: Frail patients are unlikely to make a good recovery after in-hospital arrest. This should be taken into account when planning care with patients and their families.

Use of resuscitation plans at a tertiary Australian hospital: room for improvement.

BACKGROUND: The 'Acute Resuscitation Plan' (ARP) is a document for recording the resuscitation plans of patients at a tertiary hospital for adult patients. The ARP was introduced at the hospital in September 2014, superseding the 'Not for Cardiopulmonary Resuscitation (CPR)' form. Unlike the Not for CPR form, the ARP was relevant to patients with and without resuscitation limits. AIM: To evaluate the introduction of the ARP. METHODS: This study is a retrospective audit of the records of all admissions to the hospital from January to June 2014 (Not for CPR period) and January to June 2015 (ARP period). The main outcomes are the incidence of resuscitation plans, the proportion of ARP specifying consultation with the patient (or representative) and with senior medical staff, and the proportion of ARP among older patients and those with significant comorbidity. RESULTS: Resuscitation plans were present for 453 of 23 325 (1.9%) admissions in the Not for CPR period versus 1801 of 24 037 (7.5%) in the ARP period (odds ratio (OR) 4.1, 95% confidence interval (CI) 3.7-4.5, P < 0.001). A total of 42% of ARP specified 'care of the dying' in the event of arrest. Acknowledgement of the views of the patient (or representative) was indicated on 37% of ARP and of a senior physician on 28%. An ARP was not present for 67% of patients aged ≥90 years, 59% from aged care, 90% with metastatic cancer and 64% aged ≥80 years and with a Charlson comorbidity index ≥3. CONCLUSIONS: More patients had resuscitation plans after introducing the ARP. However, patients and senior physicians were often remote from the consultation process, and an ARP was not present for many patients likely to have a poor outcome from cardiopulmonary arrest.

Changing clinical guidelines from delayed to early aperient administration for enterally fed intensive care patients was associated with increased diarrhoea: a before-and-after, intention-to-treat evaluation.

BACKGROUND: The 14-bed intensive care unit of a tertiary referral hospital adopted a guideline to start docusate sodium with sennosides when enteral nutrition was started. This replaced a guideline to start aperients after 24h of enteral nutrition if no bowel action had occurred. We sought to determine the effect of this change on the incidence of diarrhoea and constipation in intensive care. METHODS: Retrospective audit of the medical records of consecutive adult patients admitted to intensive care and given enteral nutrition, excluding those with a primary gastrointestinal system diagnosis, between Jan-Aug 2011 (the delayed group, n=175) and Jan-Aug 2012 (the early group, n=175). The early aperient guideline was implemented during Sep-Dec 2011. RESULTS: The early and delayed groups were similar in age (median 62 years vs. 64 years; P=0.17), sex (males 65% vs. 63%; P=0.91), and postoperative cases (31% vs. 33%; P=0.82) and had similar proportions who received mechanical ventilation (95% vs. 95%; P=1.00), an inotrope or vasopressor (63% vs. 70%; P=0.17), renal replacement therapy (8% vs. 10%; P=0.71), opiates (77% vs. 80%; P=0.60), antibiotics (89% vs. 91%; P=0.72) and metoclopramide (46% vs. 55%; P=0.11). A significantly larger proportion of the early group received an aperient (54% vs. 29%, P<0.001) and experienced diarrhoea (38% vs. 27%, P=0.04), but the groups had similar proportions affected by constipation (42% vs. 43%, P=0.91). CONCLUSIONS: Changing guidelines from delayed to early aperient administration was associated with an increase in the incidence of diarrhoea but was not associated with the incidence of constipation. These findings do not support changing guidelines from delayed to early aperient administration.

Do outlier inpatients experience more emergency calls in hospital? An observational cohort study.

OBJECTIVE: To determine the effect of spending time as an outlier (ie, an inpatient who spends time away from his or her "home" ward) on the frequency of emergency calls for patients admitted to a tertiary referral hospital. DESIGN, SETTING AND PATIENTS: Observational cohort study of all patients admitted to a university-affiliated tertiary referral hospital in Melbourne, Victoria, between 1 July 2009 and 30 November 2011. MAIN OUTCOME MEASURE: The number of emergency calls per hospital admission, with reference to location within the hospital. RESULTS: There were 58,158 admissions during the study period. The median age of admitted patients was 61 years, 55% were male, and the inhospital mortality was 1.40%. In 11,034 admissions (18.97%), patients spent time as outliers. Inhospital mortality was 2.57% in the outlier group versus 1.12% in the non-outlier group (P < 0.001). After adjusting for age, same-day admission, 10-year predicted mortality, interhospital transfer and high-risk clinical units, outlier status was associated with a 53% increase in emergency calls (P < 0.001). CONCLUSIONS: This study found a strong association between time spent away from a patient's home ward and the number of emergency calls. We postulate that outlier patients are at risk as they may have therapeutic and monitoring needs that are only available on their home ward. With increasing pressure to move patients out of the emergency department, the number of outlier patients may increase.

Rapid response team diagnoses: frequencies and related hospital mortality.

OBJECTIVES: To describe the frequency and hospital mortality of problems (diagnoses) encountered by a rapid response team (RRT), and to identify the most common diagnoses for RRT triggers and for treating units. DESIGN: For each RRT event in 2015 at a tertiary hospital for adults, we chose the diagnosis that best explained the RRT event from a pre-defined list after reviewing relevant test results and clinical notes. RESULTS: There were 937 RRT events during 700 admissions and there were 58 different RRT diagnoses in 11 diagnosis groups. The largest groups were neurological and consciousness problems (22.9%), circulatory problems (19.0%) and breathing problems (16.0%). The most common diagnoses were rapid atrial fibrillation (7.6%) and oversedation or narcosis (4.8%). When SpO2 < 90% triggered RRT review, the leading diagnoses were complex respiratory failure (25.9%) and pneumonia (11.4%). When decreased conscious state triggered review, the main problems were neurological, but there were 39 different diagnoses among these cases. The main problems among orthopaedic cases were post-operative hypovolaemia (19.0%) and spinal anaesthetic-related or epidural analgesicrelated hypotension (15.2%). Hospital mortality was 101/700 (14.4%). Diagnoses with high mortality included gastrointestinal bleeding (4/17, 23.5%), complex respiratory failure (8/33, 24.2%), intracranial event (8/28, 28.6%), cardiogenic shock or acute heart failure (5/17, 29.4%), pneumonia (7/21, 33.3%), chest sepsis (5/11, 45.5%) and cardiac arrest (18/26, 69.2%). CONCLUSIONS: The RRT activation trigger provides only a general indication of the diagnosis. Some problems appear preventable and could provide a focus for unit-based quality initiatives. The mortality of some diagnoses is substantial, and this may help in setting treatment goals, but more work is needed to understand the association of RRT diagnosis and outcome.

Do we practise low tidal-volume ventilation in the intensive care unit? a 14-year audit.

BACKGROUND: Low tidal volume ventilation (LTVV) has been shown to reduce mortality of patients with acute lung injury (ALI) but uptake by clinicians has been low. Recent studies have shown that LTVV results in survival benefit at 24 months after discharge and, importantly, benefits patients without ALI. OBJECTIVE: To determine adherence to LTVV in patients on mechanical ventilation (MV). DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of ventilator settings recorded within the clinical information system of a 15-bed general ICU in a tertiary referral hospital, between 1 January 2000 and 31 May 2013. METHODS: Analysis of mandatory MV with volume or pressure control. MAIN OUTCOME MEASURES: Adherence to LTVV (_6.5 mL/ kg predicted body weight [PBW]). RESULTS: We studied 4923 patients with a median age of 66 years (interquartile range [IQR], 57-74 years), and a median Acute Physiology and Chronic Health Evaluation II score of 16 (IQR, 13-19). Included were 3486 men (70.8%), and 3386 (66.8%) had undergone cardiac surgery. There were 249 450 ventilator measurements, with a median per patient of 75 measurements (IQR, 17-255 measurements). The median tidal volume was 8.15 mL/kg PBW (IQR, 7.15- 9.34 mL/kg PBW) for an adherence of 13.4%. Independent factors associated with adherence were sex, high inspiratory pressures, high positive end expiratory pressure and low PaO2/FiO2 ratio. CONCLUSION: Adherence to LTVV in a general cohort of ICU patients was low, but it was better in patients with more severe lung disease. Overestimation of PBW may have contributed to our findings. Regular auditing of LTVV adherence might be considered a clinical indicator of good MV practice.

The duration of hospitalization before review by the rapid response team: A retrospective cohort study.

PURPOSE: The purpose of this study is to compare cases of rapid response team (RRT) review for early deterioration (<48 hours after admission), intermediate deterioration (48 to <168 hours after admission), late deterioration (≥168 hours after admission), and cardiac arrest and to determine the association between duration of hospitalization before RRT review and mortality. METHODS: This is a retrospective cohort study of RRT cases from a single hospital over 5 years (2009-2013) using administrative data and data for the first RRT attendance of each hospital episode. RESULTS: Of 2843 RRT cases, 971 (34.2%) were early deterioration, 917 (32.3%) intermediate, 775 (27.3%) late, and 180 (6.3%) cardiac arrest. Compared with early deterioration patients, late deterioration patients were older (median, 71 vs 69 years; P = .005), had a higher Charlson comorbidity index (median, 2 vs 1; P < .001), more often had RRT review for respiratory distress (32.5% vs 23.5%; P < .001), more often received RRT-initiated not for resuscitation orders (8.4% vs 3.9%; P < .001), less often were discharged directly home (27.9% vs 58.4%; P < .001), and more often died in hospital (30.6% vs 12.8%; P < .001). Compared with early deterioration and adjusted for confounders, the odds ratio of death in hospital for late deterioration was 2.36 (1.81-3.08; P < .001). CONCLUSIONS: Late deterioration is frequently encountered by the RRT and, compared with early deterioration, is associated with greater clinical complexity and a worse hospital outcome.

The mortality associated with review by the rapid response team for non-arrest deterioration: a cohort study of acute hospital adult patients.

OBJECTIVES: To compare the admission characteristics, discharge destination and mortality of patients reviewed by the rapid response team (RRT) for deterioration with those of other hospital patients; and to determine the association between RRT review for deterioration and mortality. DESIGN, SETTING AND PATIENTS: Acute admissions of adult patients to a tertiary hospital between 1 January 2008 and 31 December 2011 were identified from administrative data. Data for each patient's first admission were merged with RRT data on the first RRT event of each admission, if any. RRT events involving cardiac arrest were classified as arrest events and all others as deterioration events. RESULTS: Of 43 385 patients in the cohort, 1117 (2.57%) had RRT review for deterioration and 91 (0.21%) for cardiac arrest. Deterioration events occurred a median of 3.23 days after admission. Advanced treatments were instituted in 38.59% of deterioration events, and a new not-for resuscitation order for 5.55%. Compared with those not reviewed by the RRT, patients in the deterioration group were older (median, 70 v 60 years, P < 0.001) and had a higher Charlson comorbidity index (median, 1 v 0, P < 0.001). They also more often died in hospital (18.80% v 1.42%, P < 0.001) or were discharged to another hospital (37.51% v 13.39%, P < 0.001) and more often died in the 90 days after admission (24.44% v 3.48%, P < 0.001). Their adjusted odds ratio of death in the 90 days after admission was 5.85 (95% CI, 4.97-6.89, P < 0.001). CONCLUSION: Patients reviewed for deterioration were older and had greater comorbidity than patients the RRT was not called to review. RRT review for deterioration was an independent risk factor for mortality.

Paleoindian settlement of the high-altitude Peruvian Andes.

Study of human adaptation to extreme environments is important for understanding our cultural and genetic capacity for survival. The Pucuncho Basin in the southern Peruvian Andes contains the highest-altitude Pleistocene archaeological sites yet identified in the world, about 900 meters above confidently dated contemporary sites. The Pucuncho workshop site [4355 meters above sea level (masl)] includes two fishtail projectile points, which date to about 12.8 to 11.5 thousand years ago (ka). Cuncaicha rock shelter (4480 masl) has a robust, well-preserved, and well-dated occupation sequence spanning the past 12.4 thousand years (ky), with 21 dates older than 11.5 ka. Our results demonstrate that despite cold temperatures and low-oxygen conditions, hunter-gatherers colonized extreme high-altitude Andean environments in the Terminal Pleistocene, within about 2 ky of the initial entry of humans to South America.

Fluid therapy using a balanced crystalloid solution and acid-base stability after cardiac surgery.

OBJECTIVE: To evaluate the effect of fluid therapy using Accusol (Baxter Healthcare, McGaw Park, Ill, USA), a crystalloid solution containing sodium bicarbonate and other electrolytes and having a strong ion difference of 35 mEq/L, on acid-base stability after cardiac surgery. DESIGN: Retrospective per-protocol comparison. SETTING: Intensive care unit of St Vincent's Hospital, a teaching hospital in Melbourne, Australia. PARTICIPANTS: Consecutive adult patients admitted in daytime hours after elective on-pump coronary artery bypass graft surgery between May and October 2008 constituted the "pre-Accusol group" (n=40), and those admitted between May and October 2009 and who were treated with Accusol constituted the "Accusol group" (n=51). MAIN OUTCOME MEASURES: The fluids and their component electrolytes administered; change in standard base excess (SBE) between the time of intensive care admission and 04:00 h the next day. RESULTS: The Accusol group received a median Accusol dose of 1.86 mL/kg/h (interquartile range, 1.51-2.20 mL/ kg/h), which accounted for 38% (SD, 10%) of the total volume of fluid administered. The change in SBE was +0.03mmol/L (95% CI, -0.57 to 0.64 mmol/L; P = 0.91) in the Accusol group compared with -2.05mmol/L (95% CI, -2.64 to -1.45; P < 0.01) in the pre-Accusol group. The strong ion difference of the electrolytes administered as components of fluid therapies was higher in the Accusol group by 55.5mEq (95% CI, 40.0 to 71.0mEq; P < 0.01). Only 8% of the Accusol group received albumin compared with 48% of the pre-Accusol group (P < 0.01). CONCLUSIONS: SBE was more stable in patients treated with Accusol. Further studies are needed to determine whether use of solutions such as Accusol influences important patient outcomes.

Predicted body weight during mechanical ventilation: using arm demispan to aid clinical assessment.

INTRODUCTION: Recent research suggests an association between the development of acute lung injury (ALI) and mechanical ventilation with tidal volumes > 6mL per kg of predicted body weight (BW). Specific subgroups (women and obese patients) may be at risk of unintentional delivery of excessive tidal volumes. We conducted a prospective audit of delivered tidal volumes (mL/kg) calculated using recorded BW and compared these to volumes calculated using predicted BW. PARTICIPANTS AND SETTING: Patients requiring controlled mechanical ventilation admitted to a mixed intensive care unit in October 2006 were eligible. Exclusion criteria were ALI on admission or no recorded BW (defined as a weight measured by scales or a dietitian-estimated weight) for the current admission. METHODS: Arm demispan was used to calculate height, and predicted BW was derived using ARDSNet formulas. Hourly Day 1 tidal volumes were downloaded from the medical record, and the mean for each patient was calculated. Volumes (mL/kg) were calculated using predicted and recorded BW. Data are presented as mean (SD) or median (interquartile range) depending on normality. The Mann-Whitney rank sum test was used for comparisons. RESULTS: 34 patients were studied (20 men) with a mean age of 60.6 (SD, 13.3) years and mean APACHE II score of 19.5 (SD, 6.1). Predicted BW was lower than recorded BW (69.0 [61.0-74.8] v 75 [65-85] kg; P < 0.05). Median tidal volumes (mL) were higher for men than women (552 [530- 586] v 474 [424-500] ; P < 0.01). Tidal volumes expressed as mL/kg were higher when calculated from predicted BW than from recorded BW (7.8 [7.3-8.3] v 7.2 [6.3-7.9]; P<0.05). Volumes calculated using predicted BW were higher among women than men (8.2 [7.8-8.7] v 7.5 [6.8-8]mL/kg; P < 0.05). The difference in volume between the sexes using recorded weight was not significant (7.5 [6.6-8.6] v 6.9 [6.2-7.8]mL/kg; P=0.42). CONCLUSION: Predicted BW was significantly less than recorded BW. Consequently, larger tidal volumes were delivered on a mL/kg basis when calculated using predicted BW than recorded BW. This was particularly so for women, who received higher volumes than men when using predicted BW. Calculating predicted BW using demispan as a surrogate marker of height is a cheap, easy and noninvasive tool for clinical assessment; its use in the ICU may result in the delivery of more appropriate tidal volumes.

Tayside-Fife clinical trial of cognitive-behavioural therapy for medication-resistant psychotic symptoms. Results to 3-month follow-up.

BACKGROUND: Evidence for the efficacy of cognitive-behavioural therapy for schizophrenia is promising but evidence for clinical effectiveness is limited. AIMS: To test the effectiveness of cognitive-behavioural therapy delivered by clinical nurse specialists in routine practice. METHOD: Of 274 referrals, 66 were allocated randomly to 9 months of treatment as usual (TAU), cognitive-behavioural therapy plus TAU (CBT) or supportive psychotherapy plus TAU (SPT) and followed up for 3 months. RESULTS: Treatment effects were modest but the CBT condition gave significantly greater improvement in overall symptom severity than the SPT or TAU conditions combined (F (1,53)=4.14; P=0.05). Both the CBT and SPT conditions combined gave significantly greater improvement in severity of delusions than did the TAU condition (F (1,53)=4.83; P=0.03). Clinically significant improvements were achieved by 7/21 in the CBT condition (33%), 3/19 in the SPT condition (16%) and 2/17 in the TAU condition (12%). CONCLUSIONS: Cognitive-behavioural therapy delivered by clinical nurse specialists is a helpful adjunct to routine care for some people with chronic psychosis.