Patient outcomes following medical emergency team review on general wards: Development of predictive models.

AIM: To develop and internally validate risk prediction models for subsequent clinical deterioration, unplanned ICU admission and death among ward patients following medical emergency team (MET) review. DESIGN: A retrospective cohort study of 1500 patients who remained on a general ward following MET review at an Australian quaternary hospital. METHOD: Logistic regression was used to model (1) subsequent MET review within 48 h, (2) unplanned ICU admission within 48 h and (3) hospital mortality. Models included demographic, clinical and illness severity variables. Model performance was evaluated using discrimination and calibration with optimism-corrected bootstrapped estimates. Findings are reported using the TRIPOD guideline for multivariable prediction models for prognosis or diagnosis. There was no patient or public involvement in the development and conduct of this study. RESULTS: Within 48 h of index MET review, 8.3% (n = 125) of patients had a subsequent MET review, 7.2% (n = 108) had an unplanned ICU admission and in-hospital mortality was 16% (n = 240). From clinically preselected predictors, models retained age, sex, comorbidity, resuscitation limitation, acuity-dependency profile, MET activation triggers and whether the patient was within 24 h of hospital admission, ICU discharge or surgery. Models for subsequent MET review, unplanned ICU admission, and death had adequate accuracy in development and bootstrapped validation samples. CONCLUSION: Patients requiring MET review demonstrate complex clinical characteristics and the majority remain on the ward after review for deterioration. A risk score could be used to identify patients at risk of poor outcomes after MET review and support general ward clinical decision-making. RELEVANCE TO CLINICAL PRACTICE: Our risk calculator estimates risk for patient outcomes following MET review using clinical data available at the bedside. Future validation and implementation could support evidence-informed team communication and patient placement decisions.

Nurse-Led Randomized Controlled Trials in the Perioperative Setting: A Scoping Review.

PURPOSE: Nurses provide care at each phase of the complex, perioperative pathway and are well placed to identify areas of care requiring investigation in randomized controlled trials. Yet, currently, the scope of nurse-led randomized controlled trials conducted within the perioperative setting are unknown. This scoping review aims to identify areas of perioperative care in which nurse-led randomized controlled trials have been conducted, to identify issues impacting upon the quality of these trials and identify gaps for future investigation. METHODS: This scoping review was conducted in reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Searches were conducted in PubMed, Embase, Cumulative Index for Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials, with a date range of 2014-19. Sources of unpublished literature included Open Grey, and ProQuest Dissertation and Theses, Clinical Trials.gov and the Australian and New Zealand Clinical Trials Registry. After title and abstract checking, full-text retrieval and data extraction, studies were appraised using the Joanna Briggs Institute Critical Appraisal Checklists for randomized controlled trials. Data were synthesized according to the main objectives. Key information was tabulated. RESULTS: From the 86 included studies, key areas where nurses have led randomized controlled trials include patient or caregiver anxiety; postoperative pain relief; surgical site infection prevention: patient and caregiver knowledge; perioperative hypothermia prevention; postoperative nausea and vomiting; in addition to other diverse outcomes. Issues impacting upon quality (including poorly reported randomization), and gaps for future investigation (including a focus on vulnerable populations), are evident. CONCLUSION: Nurse-led randomized controlled trials in the perioperative setting have focused on key areas of perioperative care. Yet, opportunities exist for nurses to lead experimental research in other perioperative priority areas and within different populations that have been neglected, such as in the population of older adults undergoing surgery.