Predictive value of a tiered escalation response system: A case control study.

OBJECTIVE: Rapid response systems designed to detect and respond to clinical deterioration often incorporate a multitiered, escalation response. We sought to determine the 'predictive strength' of commonly used triggers, and tiers of escalation, for predicting a rapid response team (RRT) call, unanticipated intensive care unit admission, or cardiac arrest (events). DESIGN: This was a nested, matched case-control study. SETTING: The study setting involved a tertiary referral hospital. PARTICIPANTS: Cases experienced an event, and controls were matched patients without an event. OUTCOME MEASURES: Sensitivity and specificity and area under the receiver operating characteristic curve (AUC) were measured. Logistic regression determined the set of triggers with the highest AUC. RESULTS: There were 321 cases and 321 controls. Nurse triggers occurred in 62%, medical review triggers in 34%, and RRT triggers 20%. Positive predictive value of nurse triggers was 59%, that of medical review triggers was 75%, and that of RRT triggers was 88%. These values were no different when modifications to triggers were considered. The AUC was 0.61 for nurses, 0.67 for medical review, and 0.65 for RRT triggers. With modelling, the AUC was 0.63 for the lowest tier, 0.71 for next highest, and 0.73 for the highest tier. CONCLUSION: For a three-tiered system, at the lowest tier, specificity of triggers decreases, sensitivity increases, but the discriminatory power is poor. Thus, there is little to be gained by using a rapid response system with more than two tiers. Modifications to triggers reduced the potential number of escalations and did not affect tier discriminatory value.

Outcomes for the first wave of hospitalised patients with COVID-19 in the South Australian context: a retrospective audit.

BACKGROUND: The first case of corona virus disease (COVID-19) was detected in South Australia on 1 February 2020. The Royal Adelaide Hospital (RAH) is the state's designated quarantine hospital. AIM: To determine the characteristics, outcomes and predictors of outcomes for hospitalised patients with coronavirus disease (COVID-19) within the RAH. METHODS: We performed a retrospective audit of 103 patients diagnosed with COVID-19 who were discharged from the RAH between 14 February and 21 May 2020. We collected demographic, clinical and laboratory data through an audit of electronic medical records. The main outcome measures were: (i) the need for oxygen supplementation; (ii) need for intensive care unit (ICU) care; and (iii) death in hospital. RESULTS: The median age of patients was 60 years (range 19-85). A total of 55 (53%) patients was male. All patients were independent at baseline; 37 (36%) patients suffered from hypertension. Cardiovascular disease, respiratory disease and diabetes were present in fewer than 19 (18%) patients. Obesity was present in 24 (23%) patients; 39 (38%) patients required supplemental oxygen, 18 (17%) required ICU care and 4 (4%) patients died. Older patients were significantly more at risk of oxygen requirement (median 68 vs 57.5 years, P < 0.01), ICU admission (median 66.5 vs 60 years, P = 0.04) and death (median 74.5 vs 60 years, P = 0.02). We did not find a statistically significant association between gender, body mass index and poor outcomes. Lactate dehydrogenase (LDH) was the only parameter at admission associated with oxygen requirement, ICU care and death. Peak LDH, aspartate aminotransferase, alanine aminotransferase, C-reactive protein and neutrophil lymphocyte ratio were significantly associated with oxygen requirement, ICU admission and death (P < 0.05 for all of the above laboratory markers). CONCLUSIONS: Although our sample size was small, we found that certain comorbidities and laboratory values were associated with poor outcomes. This occurred in a setting where care was not influenced by limited hospital and intensive care beds.

Optimising the response to acute clinical deterioration: the role of observation and response charts.

We sought the role of the hospital inpatient observation and response chart (ORC) in reducing adverse outcomes. We sourced articles written in English and published in PubMed. Track, trigger and response systems can be tiered and use single parameter or aggregate scoring systems; the latter being more prone to error. The documentation and detection of abnormal vital signs can be affected by choice of trigger and response and by ORC design. There is considerable variation in the design of ORC and of rapid response systems (RRS) in general, and this impairs assessment of their efficacy. A high rate of modification of pre-determined triggers and poor sensitivity of measured outcomes further compromise systematic review. The best-designed ORC and RRS should optimise the frequency of response team activation to minimise adverse patient outcomes without excess resource utilisation. The role and the risks of electronic data recording are under-explored. Detecting and responding to deteriorating patients relies upon accurate and clear documentation of vital signs. ORC design and staff education on ORC implementation and usage are integral to minimising ALF and optimising patient outcomes. Standardisation of the design of both the ORC and the hospital RRS are overdue.

Choosing medical assessments: Does the multiple-choice question make the grade?

Background: The multiple-choice question (MCQ) has been shown to measure the same constructs as the short-answer question (SAQ), yet the use of the latter persists. The study aims to evaluate whether assessment using the MCQ alone provides the same outcomes as testing with the SAQ. Methods: A prospective study design was used. A total of 276 medical students participated in a mock examination consisting of forty MCQs paired to forty SAQs, each pair matched in cognitive skill level and content. Each SAQ was marked by three independent markers. The impact of item-writing flaws (IWFs) on examination outcome was also evaluated. Results: The intraclass correlation coefficient (ICC) was 0.75 for the year IV examinations and 0.68 for the year V examinations. MCQs were more prone to IWFs than SAQs, but the effect when present in the latter was greater. Removal of questions containing IWFs from the year V SAQ allowed 39% of students who would otherwise have failed to pass. Discussion: The MCQ can test higher order skills as effectively as the SAQ and can be used as a single format in written assessment provided quality items testing higher order cognitive skills are used. IWFs can have a critical role in determining pass/fail results.

Tiered escalation response systems in practice: A post hoc analysis examining the workload implications.

Objective: Many rapid response systems now have multiple tiers of escalation in addition to the traditional single tier of a medical emergency team. Given that the benefit to patient outcomes of this change is unclear, we sought to investigate the workload implications of a multitiered system, including the impact of trigger modification. Design: The study design incorporated a post hoc analysis using a matched case-control dataset. Setting: The study setting was an acute, adult tertiary referral hospital. Participants: Cases that had an adverse event (cardiac arrest or unanticipated intensive care unit admission) or a rapid response team (RRT) call participated in the study. Controls were matched by age, gender, ward and time of year, and no adverse event or RRT call. Participants were admitted between May 2014 and April 2015. Main outcome measures: The main outcome measure were the number of reviews, triggers, and modifications across three tiers of escalation; a nurse review, a multidisciplinary review (MDT-admitting medical team review), and an RRT call. Results: There were 321 cases and 321 controls. Overall, there were 1948 nurse triggers, of which 1431 (73.5%) were in cases and 517 (26.5%) in controls, 798 MDT triggers (660 [82.7%] in cases and 138 [17.3%] in controls), and 379 RRT triggers (351 [92.6%] in cases and 28 [7.4%] in controls). Per patient per 24 h, there were 3.03 nurse, 1.24 MDT, and 0.59 RRT triggers. Accounting for modifications, this reduced to 2.17, 0.88, and 0.42, respectively. The proportion of triggers that were modified, so as not to trigger a review, was similar across all the tiers, being 28.6% of nurse, 29.6% of MDT, and 28.2% of RRT triggers. Per patient per 24 h, there were 0.61 nurse reviews, 0.52 MDT reviews, and 0.08 RRT reviews. Conclusions: Lower-tier triggers were more prevalent, and modifications were common. Modifications significantly mitigated the escalation workload across all tiers of a multitiered system.

Multi-Tiered Observation and Response Charts: Prevalence and Incidence of Triggers, Modifications and Calls, to Acutely Deteriorating Adult Patients.

BACKGROUND: Observation charts are the primary tool for recording patient vital signs. They have a critical role in documenting triggers for a multi-tiered escalation response to the deteriorating patient. The objectives of this study were to ascertain the prevalence and incidence of triggers, trigger modifications and escalation response (Call) amongst general medical and surgical inpatients following the introduction of an observation and response chart (ORC). METHODS: Prospective (prevalence), over two 24-hour periods, and retrospective (incidence), over entire hospital stay, observational study of documented patient observations intended to trigger one of three escalation responses, being a MER-Medical Emergency Response [highest tier], MDT-Multidisciplinary Team [admitting team], or Nurse-senior ward nurse [lowest tier] response amongst adult general medical and surgical patients. PREVALENCE: 416 patients, 321 (77.2%) being medical admissions, median age 76 years (IQR 62, 85) and 95 (22.8%) Not for Resuscitation (NFR). Overall, 193 (46.4%) patients had a Trigger, being 17 (4.1%) MER, 45 (10.8%) MDT and 178 (42.8%) Nurse triggers. 60 (14.4%) patients had a Call, and 72 (17.3%) a modified Trigger. INCIDENCE: 206 patients, of similar age, of whom 166 (80.5%) had a Trigger, 122 (59.2%) a Call, and 91 (44.2%) a modified Trigger. PREVALENCE and incidence of failure to Call was 33.2% and 68% of patients, respectively, particular for Nurse Triggers (26.7% and 62.1%, respectively). The number of Modifications, Calls, and failure to Call, correlated with the number of Triggers (0.912 [p<0.01], 0.631 [p<0.01], 0.988 [p<0.01]). CONCLUSION: Within a multi-tiered response system for the detection and response to the deteriorating patient Triggers, their Modifications and failure to Call are common, particularly within the lower tiers of escalation. The number of Triggers and their Modifications may erode the structure, compliance, and potential efficacy of structured observation and response charts within a multi-tiered response system.