Rapid response system for critically ill patients with haematological malignancies: A pre- and post-intervention study.

BACKGROUND: This study aimed to determine whether implementing a rapid response system (RRS) is associated with improved short-term outcomes in critically ill patients with haematological malignancies. METHODS: Our monocentric pre- versus post-intervention study was conducted between January 2012 and April 2020. RRS was activated at early signs of haemodynamic or respiratory failure. The primary outcome was the reduction in Sequential Organ Failure Assessment (SOFA) score on Day 3 after intensive care unit (ICU) admission. Secondary outcomes included time to ICU admission and mortality. RESULTS: A total of 209 patients with a median age of 59 years were enrolled (108 in the pre-intervention period and 101 in the post-intervention period). 22% of them had received an allogeneic transplant. The post-intervention period was associated with a shorter time to ICU admission (195 vs. 390 min, p < .001), a more frequent favourable trend in SOFA score (57% vs. 42%, adjusted odds ratio, 2.02, 95% confidence interval, 1.09 to 3.76), no significant changes in ICU (22% vs. 26%, p = .48) and 1-year (62% vs. 58%, p = .62) mortality rates. CONCLUSION: Detection of early organ failure and activation of an RRS was associated with faster ICU admission and lower SOFA scores on Day 3 of admission in critically ill patients with haematological malignancies.

Importance of specific vital signs in nurses' recognition and response to deteriorating patients: A scoping review.

AIM(S): To explore the published research related to nurses' documentation and use of vital signs in recognising and responding to deteriorating patients. DESIGN: Scoping review of international, peer-reviewed research studies. DATA SOURCES: Cumulative Index to Nursing and Allied Health Literature Complete, Medline Complete, American Psychological Association PsycInfo and Excerpta Medica were searched on 25 July 2023. REPORTING METHOD: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. RESULTS: Of 3880 potentially eligible publications, 32 were included. There were 26 studies of nurses' vital sign documentation: 21 adults and five paediatric. The most and least frequently documented vital signs were blood pressure and respiratory rate respectively. Seven studies focused on vital signs and rapid response activation or afferent limb failure. Five studies of vital signs used to trigger the rapid response system showed heart rate was the most frequent and respiratory rate and conscious state were the least frequent. Heart rate was least likely and oxygen saturation was most likely to be associated with afferent limb failure (n = 4 studies). CONCLUSION: Despite high reliance on using vital signs to recognise clinical deterioration and activate a response to deteriorating patients in hospital settings, nurses' documentation of vital signs and use of vital signs to activate rapid response systems is poorly understood. There were 21studies of nurses' vital sign documentation in adult patients and five studies related to children. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: A deeper understanding of nurses' decisions to assess (or not assess) specific vital signs, analysis of the value or importance nurses place (or not) on specific vital sign parameters is warranted. The influence of patient characteristics (such as age) or the clinical practice setting, and the impact of nurses' workflows of vital sign assessment warrants further investigation. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution.

A multi-nudge-based behavioural insight into ward nurses' respiratory rate measurement: An observational study.

AIM: This study observed changes in respiratory rate measurement (RRM) and identified barriers and challenges in clinical practice that influence healthcare worker behaviour, aiming to improve RRM in a hospital setting. DESIGN: An observational study was conducted. METHODS: We observed and analysed changes in the behaviour of healthcare workers at a hospital where multi-nudges were introduced to improve RRM. RESULTS: We checked respiration rate using electronic data and discovered that the original measurement rates were low. Measurement rates rapidly increased after posters were added. Barriers such as time constraints and measurement equipment were also noted. CONCLUSION: RRM was found to be effective in promoting behavioural economics in medical settings. The results show that incorporating behavioural science principles into medical interventions has the potential to positively change behaviour. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: By increasing nurses' awareness of respiratory rate measurement and addressing barriers to it, the measurement rate of respiratory rate can also increase, leading to more accurate patient evaluations and triage. IMPACT: WHAT PROBLEM DID THE STUDY ADDRESS?: The proportion of respiratory rate measurements leading to rapid response system (RRS) calls was low. WHAT WERE THE MAIN FINDINGS?: The study observed that a multi-nudge approach effectively changes the behaviour of ward nurses, resulting in enhanced quality of medical care. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: This research can serve as a valuable reference for leaders promoting healthcare quality projects, by offering a method to encourage behavioural change. REPORTING METHOD: This study complied with the EQUATOR guidelines and its reporting adheres to the STROBE checklist. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Nurses' experience with patient deterioration and rapid response teams.

BACKGROUND: While timely activation and collaborative teamwork of Rapid Response Teams (RRTs) are crucial to promote a culture of safety and reduce preventable adverse events, these do not always occur. Understanding nurses' perceptions of and experiences with RRTs is important to inform education and policy that improve nurse performance, RRT effectiveness, and patient outcomes. AIM: The aim of this study was to explore nurse perceptions of detecting patient deterioration, deciding to initiate RRTs, and experience during and at conclusion of RRTs. METHODS: A qualitative descriptive study using semi-structured focus group interviews was conducted with 24 nurses in a Chicago area hospital. Interviews were audio-recorded, transcribed verbatim, and coded independently by investigators. Thematic analysis identified and organized patterns of meaning across participants. Several strategies supported trustworthiness. RESULTS: Data revealed five main themes: identification of deterioration, deciding to escalate care, responsiveness of peers/team, communication during rapid responses, and perception of effectiveness. CONCLUSIONS: Findings provide insight into developing a work environment supportive of nurse performance and interprofessional collaboration to improve RRT effectiveness. Nurses described challenges in identification of subtle changes in patient deterioration. Delayed RRT activation was primarily related to negative attitudes of responders and stigma. RRT interventions were often considered a temporary fix leading to subsequent RRTs, especially when patients needing a higher level of care were not transferred. Implications include the need for ongoing RRT monitoring and education on several areas such as patient hand-off, RRT activation, nurse empowerment, interprofessional communication, role delineation, and code status discussions.

General ward nurses detection and response to clinical deterioration in three hospitals at the Kenyan coast: a convergent parallel mixed methods study.

BACKGROUND: In low and middle-income countries like Kenya, critical care facilities are limited, meaning acutely ill patients are managed in the general wards. Nurses in these wards are expected to detect and respond to patient deterioration to prevent cardiac arrest or death. This study examined nurses' vital signs documentation practices during clinical deterioration and explored factors influencing their ability to detect and respond to deterioration. METHODS: This convergent parallel mixed methods study was conducted in the general medical and surgical wards of three hospitals in Kenya's coastal region. Quantitative data on the extent to which the nurses monitored and documented the vital signs 24 h before a cardiac arrest (death) occurred was retrieved from patients' medical records. In-depth, semi-structured interviews were conducted with twenty-four purposefully drawn registered nurses working in the three hospitals' adult medical and surgical wards. RESULTS: This study reviewed 405 patient records and found most of the documentation of the vital signs was done in the nursing notes and not the vital signs observation chart. During the 24 h prior to death, respiratory rate was documented the least in only 1.2% of the records. Only a very small percentage of patients had any vital event documented for all six-time points, i.e. four hourly. Thematic analysis of the interview data identified five broad themes related to detecting and responding promptly to deterioration. These were insufficient monitoring of vital signs linked to limited availability of equipment and supplies, staffing conditions and workload, lack of training and guidelines, and communication and teamwork constraints among healthcare workers. CONCLUSION: The study showed that nurses did not consistently monitor and record vital signs in the general wards. They also worked in suboptimal ward environments that do not support their ability to promptly detect and respond to clinical deterioration. The findings illustrate the importance of implementation of standardised systems for patient assessment and alert mechanisms for deterioration response. Furthermore, creating a supportive work environment is imperative in empowering nurses to identify and respond to patient deterioration. Addressing these issues is not only beneficial for the nurses but, more importantly, for the well-being of the patients they serve.

European survey on Paediatric Early Warning Systems, and other processes used to aid the recognition and response to children's deterioration on hospital wards.

BACKGROUND: Internationally, there is an increasing trend in using Rapid Response Systems (RRS) to stabilize in-patient deterioration. Despite a growing evidence base, there remains limited understanding of the processes in place to aid the early recognition and response to deteriorating children in hospitals across Europe. AIM/S: To describe the processes in place for early recognition and response to in-patient deterioration in children in European hospitals. STUDY DESIGN: A cross-sectional opportunistic multi-centre European study, of hospitals with paediatric in-patients, using a descriptive self-reported, web-based survey, was conducted between September 2021 and March 2022. The sampling method used chain referral through members of European and national societies, led by country leads. The survey instrument was an adaptation to the survey of Recognition and Response Systems in Australia. The study received ethics approval. Descriptive analysis and Chi-squared tests were performed to compare results in European regions. RESULTS: A total of 185 questionnaires from 21 European countries were received. The majority of respondents (n = 153, 83%) reported having written policies, protocols, or guidelines, regarding the measurement of physiological observations. Over half (n = 120, 65%) reported that their hospital uses a Paediatric Early Warning System (PEWS) and 75 (41%) reported having a Rapid Response Team (RRT). Approximately one-third (38%) reported that their hospital collects specific data about the effectiveness of their RRS, while 100 (54%) reported providing regular training and education to support it. European regional differences existed in PEWS utilization (North = 98%, Centre = 25%, South = 44%, p < .001) and process evaluation (North = 49%, Centre = 6%, South = 36%, p < .001). CONCLUSIONS: RRS practices in European hospitals are heterogeneous. Differences in the uptake of PEWS and RRS process evaluation emerged across Europe. RELEVANCE TO CLINICAL PRACTICE: It is important to scope practices for the safe monitoring and management of deteriorating children in hospital across Europe. To reduce variance in practice, a consensus statement endorsed by paediatric and intensive care societies could provide guidance and resources to support PEWS implementation and for the operational governance required for continuous quality improvement.

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.

Prospective, multicenter validation of the deep learning-based cardiac arrest risk management system for predicting in-hospital cardiac arrest or unplanned intensive care unit transfer in patients admitted to general wards.

BACKGROUND: Retrospective studies have demonstrated that the deep learning-based cardiac arrest risk management system (DeepCARS™) is superior to the conventional methods in predicting in-hospital cardiac arrest (IHCA). This prospective study aimed to investigate the predictive accuracy of the DeepCARS™ for IHCA or unplanned intensive care unit transfer (UIT) among general ward patients, compared with that of conventional methods in real-world practice. METHODS: This prospective, multicenter cohort study was conducted at four teaching hospitals in South Korea. All adult patients admitted to general wards during the 3-month study period were included. The primary outcome was predictive accuracy for the occurrence of IHCA or UIT within 24 h of the alarm being triggered. Area under the receiver operating characteristic curve (AUROC) values were used to compare the DeepCARS™ with the modified early warning score (MEWS), national early warning Score (NEWS), and single-parameter track-and-trigger systems. RESULTS: Among 55,083 patients, the incidence rates of IHCA and UIT were 0.90 and 6.44 per 1,000 admissions, respectively. In terms of the composite outcome, the AUROC for the DeepCARS™ was superior to those for the MEWS and NEWS (0.869 vs. 0.756/0.767). At the same sensitivity level of the cutoff values, the mean alarm counts per day per 1,000 beds were significantly reduced for the DeepCARS™, and the rate of appropriate alarms was higher when using the DeepCARS™ than when using conventional systems. CONCLUSION: The DeepCARS™ predicts IHCA and UIT more accurately and efficiently than conventional methods. Thus, the DeepCARS™ may be an effective screening tool for detecting clinical deterioration in real-world clinical practice. Trial registration This study was registered at ClinicalTrials.gov ( NCT04951973 ) on June 30, 2021.

Vital sign assessment and nursing interventions in medical and surgical patients with rapid response system triggers.

AIM(S): To explore vital sign assessment (both complete and incomplete sets of vital signs), and escalation of care per policy and nursing interventions in response to clinical deterioration. DESIGN: This cohort study is a secondary analysis of data from the Prioritising Responses of Nurses To deteriorating patient Observations cluster randomised controlled trial of a facilitation intervention on nurses' vital sign measurement and escalation of care for deteriorating patients. METHODS: The study was conducted in 36 wards at four metropolitan hospitals in Victoria, Australia. Medical records of all included patients from the study wards during three randomly selected 24-h periods within the same week were audited at three time points: pre-intervention (June 2016), and at 6 (December 2016) and 12 months (June 1017) post-intervention. Descriptive statistics were used to summarise the study data, and relationships between variables were examined using chi-square test. RESULTS: A total of 10,383 audits were conducted. At least one vital sign measurement was documented every 8 h in 91.6% of audits, and a complete set of vital signs was documented every 8 h in 83.1% of audits. There were pre-Medical Emergency Team, Medical Emergency Team or Cardiac Arrest Team triggers in 25.8% of audits. When triggers were present, a rapid response system call occurred in 26.8% of audits. There were 1350 documented nursing interventions in audits with pre-Medical Emergency Team (n = 2403) or Medical Emergency Team triggers (n = 273). One or more nursing interventions were documented in 29.5% of audits with pre-Medical Emergency Team triggers and 63.7% of audits with Medical Emergency Team triggers. CONCLUSION: When rapid response system triggers were documented, there were gaps in escalation of care per policy; however, nurses undertook a range of interventions within their scope of practice in response to clinical deterioration. RELEVANCE TO CLINICAL PRACTICE: Medical and surgical ward nurses in acute care wards frequently engage in vital sign assessment. Interventions by medical and nurgical nurses may occur prior to, or in parallel with calling the rapid response system. Nursing interventions are a key but under-recognised element of the organisational response to deteriorating patients. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Nurses engage in a range of nursing interventions to manage deteriorating patients, (aside from rapid response system activation) that are not well understood, nor well described in the literature to date. IMPACT: This study addresses the gap in the literature regarding nurses' management of deteriorating patients within their scope of practice (aside from RRS activation) in real world settings. When rapid response system triggers were documented, there were gaps in escalation of care per policy; however, nurses undertook a range of interventions within their scope of practice in response to clinical deterioration. The results of this research are relevant to nurses working on medical and surgical wards. REPORTING METHOD: The trial was reported according to the Consolidated Standards of Reporting Trials extension for Cluster Trials recommendations, and this paper is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology Statement. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution.

A Delphi study to obtain consensus on medical emergency team (MET) stand-down decision making.

AIM: A medical emergency team (MET) stand-down decision is the decision to end a MET response and hand responsibility for the patient back to ward staff for ongoing management. Little research has explored this decision. This study aimed to obtain expert consensus on the essential elements required to make optimal MET call stand-down decisions and the communication required before MET departure. DESIGN: A Delphi design was utilised. METHODS: An expert panel of 10 members were recruited based on their expert knowledge and recent clinical MET responder experience in acute hospital settings. Participants were emailed a consent form and an electronic interactive PDF for each survey. Two rounds were conducted with no attrition between rounds. The CREDES guidance on conducting and reporting Delphi studies was used to report this study. RESULTS: Consensus by an expert panel of 10 MET responders generated essential elements of MET stand-down decisions. Essential elements comprised of two steps: (1) the stand-down decision that was influenced by both the patient situation and the ward/organisational context; and (2) the communication required before actioning stand-down. Communication after the decision required both verbal discussions and written documentation to hand over patient responsibility. Specific patient information, a management plan and an escalation plan were considered essential. CONCLUSION: The Delphi surveys reached consensus on the actions and communication required to stand down a MET call. Passing responsibility back to ward staff after a MET call requires both patient and ward safety assessments, and a clearly articulated patient plan for ward staff. Observation of MET call stand-down decision-making is required to validate the essential elements. IMPLICATION FOR THE PROFESSION AND PATIENT/OR PATIENT CARE: In specifying the essential elements, this study offers clinical and MET staff a process to support the handing over of clinical responsibility from the MET to the ward staff, and clarification of management plans in order to reduce repeat MET calls and improve patient outcomes. IMPACT: Minimal research has been focussed on the decision to hand responsibility back to ward staff so the MET may leave the ward with safety plan in place. This study provided expert consensus to optimise MET stand-down decision-making and the ultimate decision to end a MET call. Communication of agreed patient treatment and escalation plans is recommended before leaving the ward. This study can be used as a checklist for MET responder staff making these decisions and ward staff responsible for post-MET call care. The aim being to reduce the likelihood of potentially preventable repeat deterioration in the MET patient population. REPORTING METHOD: The CREDES guidance on conducting and reporting Delphi studies. PATIENT OR PUBLIC CONTRIBUTION: None.

Automated rapid response system activation-Impact on nurses' attitudes and perceptions towards recognising and responding to clinical deterioration: Mixed-methods study.

AIM: To explore general ward nurses' attitudes and perceptions towards recognising and responding to clinical deterioration in a hospital with automated rapid response system activation. BACKGROUND: There is growing interest in deploying automated clinical deterioration notification systems to reduce delayed or failed recognition and response to clinical deterioration of ward patients. However, little is known about its impact on ward nurses' perspectives and work patterns. DESIGN: A mixed-methods study. METHODS: Online survey of 168 registered nurses and individual interviews with 10 registered nurses in one acute hospital in Singapore. The study adhered to the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies. RESULTS: Many nurses (38.1%) rarely performed patient assessments or observations other than vital signs assessment to assess for early signs of clinical deterioration. About 30% were worried about being criticised for calling the primary team doctors. Four themes emerged from the qualitative analysis: automated rapid response system activation as a safety net, being more cautious with vital signs monitoring, the NEWS2 alone is inadequate, and ward nurses as the 'middleman' between the intensive care unit outreach nurse and primary team doctors. CONCLUSIONS: Although nurses value the automated rapid response system activation as a safety net to minimise delays in accessing urgent critical care resources, it does not address the sociocultural barriers inherent in escalation of care. Although the automated system led nurses to be more cautious with vital signs monitoring, it does not encourage them to perform comprehensive patient assessments to detect early signs of deterioration. RELEVANCE TO CLINICAL PRACTICE: Nurse education on assessing for clinical deterioration should focus on the use of broader patient assessment skills other than vital signs. Sociocultural barriers to escalation of care remain a key issue that needs to be addressed by hospital management. NO PATIENT OR PUBLIC CONTRIBUTION: No patients, service users, care-givers or members of the public were involved in the study.

Pre-medical emergency team activations - Patient characteristics, outcomes and predictors of deterioration.

BACKGROUND: Pre-medical emergency team (MET) calls are an increasingly common tier of Rapid Response Systems, but the epidemiology of patients who trigger a Pre-MET is not well understoof. OBJECTIVES: This study aims to examine the epidemiology and outcomes of patients who trigger a pre-MET activation and identify risk factors for further deterioration. METHODS: This is a retrospective cohort study of pre-MET activations in a university-affiliated metropolitan hospital in Australia, between 13 April 2021 and 4 October 2021. A multivariable regression model was used to identify variables associated with further deterioration, defined as a MET call or Code Blue within 24 h of pre-MET activation. RESULTS: From a total of 39 664 admissions, there were 7823 pre-MET activations (197.2 per 1000 admissions). Compared to inpatients that did not trigger a pre-MET, the patients were older (68.8 vs 53.8 years, p < 0.001), were more likely to be male (51.0 vs 47.6%, p < 0.001), had an emergency admission (70.1% vs 53.3%, p < 0.001), and were under a medical specialty (63.7 vs 54.9%, p < 0.001). They had a longer hospital length of stay (5.6 vs 0.4 d, p < 0.001) and higher in-hospital mortality (3.4% vs 1.0%, p < 0.001). A pre-MET was more likely to progress to a MET call or Code Blue if it was activated for fever, cardiovascular, neurological, renal, or respiratory criteria (p < 0.001), if the patient was under a paediatric team (p = 0.018), or if there had been a MET call or Code Blue prior to the pre-MET activation (p < 0.001). CONCLUSION: Pre-MET activations affect almost 20% of hospital admissions and are associated with a higher risk of mortality. Certain characteristics may predict further deterioration to a MET call or Code Blue, suggesting the potential for early intervention via clinical decision support systems.

The patient experience of a medical emergency team review: A convergent mixed-methods study.

AIMS: The aim of this study was to explore clinician-patient engagement during, and patient experience of, medical emergency team (MET) reviews. DESIGN: This study involved a convergent mixed-methods design. METHODS: This three-phase study was conducted at two hospitals of one Australian health service. Reviews by the MET were observed for clinician-patient engagement behaviours; medical records were audited to confirm patient demographics and clinical characteristics; and patients who received a MET review were interviewed. Quantitative data were analysed using descriptive statistics, and thematic analysis of qualitative interview data was conducted. RESULTS: In total, 26 MET reviews were observed for 22 patients (median age = 81.5 years and 68.2% females). Between 8 and 13 clinicians and other staff members were present during each review, with a total of 209 clinicians present during the 26 reviews. Clinicians were not observed to speak directly or indirectly to the patient about their care in 38.5% (n = 10/26) of the MET reviews, and 58.3% (n = 56/96) of interventions were performed without explanation. Four themes were identified from the interviews: An unexpected event; A lack of understanding; In good hands, and What happens next? CONCLUSION: Clinician-patient engagement was infrequent during and after MET reviews. Patients experienced surprise from the sudden arrival of clinicians in their room and had poor levels of understanding about the review. However, most patients felt supported and safe. MET reviews are frequent safety-critical events, and this study identified the patient experience of these events. Clinicians should be aware that patients expressed they were surprised and shocked by the review and that an explanation of what was being done by the clinical team was rarely offered. These findings can be used to inform strategies to improve their patient-engagement behaviours and patient-centred care.

Antecedents to and outcomes for in-hospital cardiac arrests in Australian hospitals with mature medical emergency teams: A multicentre prospective observational study.

BACKGROUND: The epidemiology and predictability of in-hospital cardiac arrests (IHCAs) in hospitals with established medical emergency teams (METs) is underinvestigated. OBJECTIVES: We categorised IHCAs into three categories: "possible suboptimal end-of-life planning" (possible SELP), "potentially predictable", or "sudden and unexpected" using age, Charlson Comorbidity Index, place of residence, functional independence, along with documented vital signs, K+ and HCO3 in the period prior to the IHCA. We also described the differences in characteristics and outcomes amongst these three categories of IHCAs. METHODS: This was a prospective observational study (1st July 2017 to 9th August 2018) of adult (18 years) IHCA patients in wards of seven Australian hospitals with well-established METs. RESULTS: Amongst 152 IHCA patients, 145 had complete data. The number (%) classified as possible SELP, potentially predictable, and sudden and unexpected IHCA was 50 (34.5%), 52 (35.8%), and 43 (29.7%), respectively. Amongst the 52 potentially predictable patients, six (11.5%) had missing vital signs in the preceding 6 hr, 18 (34.6%) breached MET criteria in the prior 24 hr but received no MET call, and 6 (11.5%) had a MET call but remained on the ward. Abnormal K+ and HCO3 was present in 15 of 51 (29.5%) and 13 of 51 (25.5%) of such patients, respectively. The 43 sudden and unexpected IHCA patients were mostly (97.6%) functionally independent and had the lowest median Charlson Comorbidity Index. In-hospital mortality for IHCAs classified as possible SELP, potentially predictable, and sudden and unexpected was 76.0%, 61.5%, and 44.2%, respectively (p = 0.007). Only four of 12 (33.3%) possible SELP survivors had a good functional outcome. CONCLUSIONS: In seven Australian hospitals with mature METs, only one-third of IHCAs were sudden and unexpected. Improving end-of-life care in elderly comorbid patients and enhancing the response to objective signs of deterioration may further reduce IHCAs in the Australian context.

Quick Sequential Organ Failure Assessment Score and the Modified Early Warning Score for Predicting Clinical Deterioration in General Ward Patients Regardless of Suspected Infection.

BACKGROUND: The quick sequential organ failure assessment (qSOFA) score is suggested to use for screening patients with a high risk of clinical deterioration in the general wards, which could simply be regarded as a general early warning score. However, comparison of unselected admissions to highlight the benefits of introducing qSOFA in hospitals already using Modified Early Warning Score (MEWS) remains unclear. We sought to compare qSOFA with MEWS for predicting clinical deterioration in general ward patients regardless of suspected infection. METHODS: The predictive performance of qSOFA and MEWS for in-hospital cardiac arrest (IHCA) or unexpected intensive care unit (ICU) transfer was compared with the areas under the receiver operating characteristic curve (AUC) analysis using the databases of vital signs collected from consecutive hospitalized adult patients over 12 months in five participating hospitals in Korea. RESULTS: Of 173,057 hospitalized patients included for analysis, 668 (0.39%) experienced the composite outcome. The discrimination for the composite outcome for MEWS (AUC, 0.777; 95% confidence interval [CI], 0.770-0.781) was higher than that for qSOFA (AUC, 0.684; 95% CI, 0.676-0.686; P < 0.001). In addition, MEWS was better for prediction of IHCA (AUC, 0.792; 95% CI, 0.781-0.795 vs. AUC, 0.640; 95% CI, 0.625-0.645; P < 0.001) and unexpected ICU transfer (AUC, 0.767; 95% CI, 0.760-0.773 vs. AUC, 0.716; 95% CI, 0.707-0.718; P < 0.001) than qSOFA. Using the MEWS at a cutoff of ≥ 5 would correctly reclassify 3.7% of patients from qSOFA score ≥ 2. Most patients met MEWS ≥ 5 criteria 13 hours before the composite outcome compared with 11 hours for qSOFA score ≥ 2. CONCLUSION: MEWS is more accurate that qSOFA score for predicting IHCA or unexpected ICU transfer in patients outside the ICU. Our study suggests that qSOFA should not replace MEWS for identifying patients in the general wards at risk of poor outcome.

Implementing a Rapid Response System in a tertiary-care hospital. A cost-effectiveness study.

PURPOSE: The occurrence of adverse events (AE) in hospitalized patients substancially increases the risk of disability or death, having a major negative clinical and economic impact on public health. For early identification of patients at risk and to establish preventive measures, different healthcare systems have implemented rapid response systems (RRS). The aim of this study was to carry out a cost-effectiveness analysis of implementing a RRS in a tertiary-care hospital. METHODS: We included all the patients admitted to Hospital Clínic de Barcelona from 1 to 2016 to 31 December 2016. The cost-effectiveness analysis was summarized as the incremental cost-effectiveness ratio (incremental cost divided by the incremental effectiveness of the two alternatives, RRS versus non-RRS). The effectiveness of the RRS, defined as improvements in health outcomes (AE, cardiopulmonary arrest and mortality), was obtained from the literature and applied to the included patient cohort. A budget impact analysis on the implementation of the RRS from a hospital perspective was performed over a 5-year time horizon. RESULTS: 42,409 patients were included, and 448 (1.05%) had severe AE requiring ICU admission. The cost-effectiveness analysis showed an incremental cost (savings) of EUR - 1,471,101 of RRS versus the non-RRS. The budgetary impact showed a cost reduction of EUR 896,762.00 in the first year and EUR 1,588,579.00 from the second to the fifth year. CONCLUSIONS: The present analysis shows the RRS as a dominant, less costly and more effective structure compared to the non-RRS.

Construct and clinical verification of a nurse-led rapid response systems and activation criteria.

BACKGROUND: Effective team leadership and good activation criteria can effectively initiate rapid response system (RRS) to reduce hospital mortality and improve quality of life. The first reaction time of nurses plays an important role in the rescue process. To construct a nurse-led (nurse-led RRS) and activation criteria and then to conduct a pragmatic evaluation of the nurse-led RRS. METHODS: We used literature review and the Delphi method to construct a nurse-led RRS and activation criteria based on the theory of "rapid response system planning." Then, we conducted a quasi-experimental study to verify the nurse-led RRS. The control group patients were admitted from August to October 2020 and performed traditional rescue procedures. The intervention group patients were admitted from August to October 2021 and implemented nurse-led RRS. The primary outcome was success rate of rescue. SETTING: Emergency department, Gansu Province, China. RESULTS: The nurse-led RRS and activation criteria include 4 level 1 indicators, 14 level 2 indicators, and 88 level 3 indicators. There were 203 patients who met the inclusion criteria to verify the nurse-led RRS. The results showed that success rate of rescue in intervention group (86.55%) was significantly higher than that in control group (66.5%), the rate of cardiac arrest in intervention group (33.61%) was significantly lower than that in control group (72.62%), the effective rescue time of intervention group (46.98 ± 12.01 min) was shorter than that of control group (58.67 ± 13.73 min), and the difference was statistically significant (P < 0.05). The rate of unplanned ICU admissions in intervention group (42.85%) was lower than that in control group (44.04%), but the difference was not statistically significant (P > 0.05). CONCLUSIONS: The nurse-led RRS and activation criteria can improve the success rate of rescue, reduce the rate of cardiac arrest, shorten the effective time of rescue, effectively improve the rescue efficiency of patients.

Effect of a Wireless Vital Sign Monitoring System on the Rapid Response System in the General Ward.

While wireless vital sign monitoring is expected to reduce the vital sign measurement time (thus reducing the nursing workload), its impact on the rapid response system is unclear. This study compared the time from vital sign measurement to recording and rapid response system activation between wireless and conventional vital sign monitoring in the general ward, to investigate the impact of wireless vital sign monitoring system on the rapid response system. The study divided 249 patients (age > 18 years; female: 47, male: 202) admitted to the general ward into non-wireless (n = 101) and wireless (n = 148) groups. Intervals from vital sign measurement to recording and from vital sign measurement to rapid response system activation were recorded. Effects of wireless system implementation for vital sign measurement on the nursing workload were surveyed in 30 nurses. The interval from vital sign measurement to recording was significantly shorter in the wireless group than in the non-wireless group (4.3 ± 2.9 vs. 44.7 ± 14.4 min, P < 0.001). The interval from vital sign measurement to rapid response system activation was also significantly lesser in the wireless group than in the non-wireless group (27.5 ± 12.9 vs. 41.8 ± 19.6 min, P = 0.029). The nursing workload related to vital sign measurement significantly decreased from 3 ± 0.87 to 2.4 ± 9.7 (P = 0.021) with wireless system implementation. Wireless vital sign monitoring significantly reduced the time to rapid response system activation by shortening the time required to measure the vital signs. It also significantly reduced the nursing workload.

Relationship between the presence of dedicated doctors in rapid response systems and patient outcome: a multicenter retrospective cohort study.

BACKGROUND: Rapid response systems (RRSs) improve patients' safety, but the role of dedicated doctors within these systems remains controversial. We aimed to evaluate patient survival rates and differences in types of interventions performed depending on the presence of dedicated doctors in the RRS. METHODS: Patients managed by the RRSs of 9 centers in South Korea from January 1, 2016, through December 31, 2017, were included retrospectively. We used propensity score-matched analysis to balance patients according to the presence of dedicated doctors in the RRS. The primary outcome was in-hospital survival. The secondary outcomes were the incidence of interventions performed. A sensitivity analysis was performed with the subgroup of patients diagnosed with sepsis or septic shock. RESULTS: After propensity score matching, 2981 patients were included per group according to the presence of dedicated doctors in the RRS. The presence of the dedicated doctors was not associated with patients' overall likelihood of survival (hazard ratio for death 1.05, 95% confidence interval [CI] 0.93‒1.20). Interventions, such as arterial line insertion (odds ratio [OR] 25.33, 95% CI 15.12‒42.44) and kidney replacement therapy (OR 10.77, 95% CI 6.10‒19.01), were more commonly performed for patients detected using RRS with dedicated doctors. The presence of dedicated doctors in the RRS was associated with better survival of patients with sepsis or septic shock (hazard ratio for death 0.62, 95% CI 0.39‒0.98) and lower intensive care unit admission rates (OR 0.53, 95% CI 0.37‒0.75). CONCLUSIONS: The presence of dedicated doctors within the RRS was not associated with better survival in the overall population but with better survival and lower intensive care unit admission rates for patients with sepsis or septic shock.

Rapid response team nurses' attitudes and barriers to the rapid response system: A multicentre survey.

BACKGROUND: Despite wide implementation of rapid response teams (RRTs), no published data exist on RRT nurses' attitudes and barriers to the rapid response system (RRS). METHODS: We piloted a 5-point Likert-type scale questionnaire among all Finnish university hospitals' RRT nurses with optional open-ended comments. The impact of more frequent RRT participation was further investigated. RESULTS: The response rate was 46% (n = 176/379, 34%-93% between hospitals). The respondents median experience on a RRT was three years (0.8-5) and median participation was two (1-5) RRT activations per month. Over 90% of the RRT nurses felt that RRS prevented cardiac arrests and improved patient safety. Nurses with five or more RRT activations/month believed their critical care skills had improved through these duties (94% vs 71%, P = .001), considered their RRT work meaningful (94% vs 76%, P = .005) and wanted to continue as RRT nurses (91% vs 74%, P = .015) more often than nurses with less than five RRT activations/month. In addition to the infrequent RRT participation, further negative experiences with RRS among the RRT nurses included feeling overworked (68%) or undercompensated (94%) for the RRT duties and conflicts between RRT and ward doctors (25%). CONCLUSION: RRT nurses consider their work important and believe it fosters improved critical care skills; these beliefs are emphasized among those with more frequent RRT participation. Infrequent RRT participation, feeling overworked and/or undercompensated and conflicts between RRT and ward doctors may present barriers for successful RRS among RRT nurses.