Modifications to rapid response team (medical emergency team) activation criteria and its impact on patient safety.

BACKGROUND: Modifications to rapid response team (RRT) activation criteria occur commonly in Australian hospitals without evidence to define their use. AIMS: To evaluate the effectiveness of RRT activation criteria modifications in preventing RRT activation and differences in adverse events associated with treatment delays caused by modifications. METHODS: A prospective chart audit of hospital patients with RRT activation criteria modifications admitted during a 12-month period in a large regional hospital in Toowoomba, Australia. The incidence of RRT activation criteria modifications, RRT activations and rates of adverse events following criteria modifications were investigated. Adverse events were defined as a delayed treatment on the ward, unplanned intensive care unit admission, cardiac arrest and unexpected death. Differences in patient outcomes among medical and surgical patients were also investigated. RESULTS: A total of 271 patients out of 4009 admitted patients had modifications to their RRT activation criteria. There was no difference in rates of RRT activation in patients with modified criteria compared with patients with unmodified criteria (P = 0.37). In patients with RRT activation criteria modifications, rates of adverse events were higher in patients who met their modified RRT criteria (93.3%) compared with those who did not meet modified RRT criteria (3.8%; P < 0.001). Additionally, in patients with modifications, rates of adverse events were higher in medical patients (27.6%; n = 50) compared with surgical patients (15.6%; n = 14; P = 0.03). CONCLUSIONS: The results strongly suggest that RRT criteria modification is associated with no difference in rates of RRT activation and with detrimental impacts on patient safety, particularly in medical patients.

Measuring the intensive care experience: A cross-sectional survey of patient and family experiences of critical care.

AIMS AND OBJECTIVES: To report patient and family intensive care experiences using the Measuring the Intensive Care Experience (MICE) tool across two intensive care units (ICU). BACKGROUND: The patient and family experience of care is an important indicator for quality improvement of ICUs, yet few studies evaluate both patient and family experiences in relation to overall care quality as well as specifically measuring quality of medical care, nursing care and organisational care as well as overall experience of the quality of intensive care. DESIGN: A cross-sectional survey. METHODS: A 23 item survey was administered to ICU patients and their family members across two ICUs, a regional 189-bed hospital and a metropolitan 227-bed hospital in Queensland, Australia. The response rate was 272 of 394 ICU patients (36.4%). STROBE guidelines were used in reporting this study. RESULTS: Findings indicate a highly positive overall experience of ICU care among patients and families. However, patients reported areas of unmet needs following their stay in ICU broadly related to (1) symptom management, education and information support, and (2) improving the incorporation of patient and family care ICU-related shared decision-making. CONCLUSIONS: Supportive interventions are needed that target improve symptom management and inform and education ICU patients. RELEVANCE TO CLINICAL PRACTICE: The MICE survey facilitated the identification of a range of areas requiring quality improvement. Improving the integration of patients and families into shared decision-making and support is a key aspect for quality improvement.

A Case Report of Preeclampsia Causing Severe Hyponatremia: Rare or Rarely Reported?

Preeclampsia presenting as severe hyponatremia is an enigma of modern obstetric practice. The hyponatremia can cause severe maternal neurological morbidity, including cerebral edema and seizures. Neonates, with serum sodium reflecting maternal levels, are also at risk. Despite this, the literature remains ambiguous about its incidence, the pathophysiology is poorly understood, and guidelines on preeclampsia (including those of the American College of Obstetricians and Gynecologists) do not discuss the issue. This case of preeclampsia associated with severe hyponatremia in a laboring woman highlights these issues.

The association between preoperative eGFR and outcomes in cardiac surgical patients.

AIM: To study the relationship between preoperative renal function and outcomes in patients undergoing cardiac surgery. DESIGN, SETTING AND PARTICIPANTS: A retrospective descriptive study was performed on all patients who had coronary artery bypass, cardiac valve surgery and/or aortic arch surgery at a tertiary-referral hospital between January 2002 and December 2007. MAIN OUTCOME MEASURES: Clinical and demographic variables were compared across renal dysfunction categories, defined by glomerular filtration rate (eGFR) calculated using the modified Modification of Diet in Renal Disease (MDRD) equation. Logistic regression was used to assess the association between eGFR and outcomes, primarily in-hospital mortality. RESULTS: 7440 patients were included, with a mean age of 64 years and overall mortality of 1.6%. Across worsening renal function states, excluding patients receiving dialysis, patients were older, more likely to be women and to have comorbidities (particularly diabetes and vascular disease), as well as ventricular dysfunction, and to require emergency or more complex surgery. Unadjusted outcomes, as well as univariate and multivariate analysis, consistently demonstrated that odds ratios for adverse events increased with worsening renal function, even at moderate levels of dysfunction. CONCLUSIONS: Preoperative renal dysfunction is independently associated with mortality after cardiac surgery. This is consistent with the accumulating evidence supporting preoperative renal dysfunction as a powerful predictor of adverse outcomes.

Effect of changes in syringe driver height on flow: a small quantitative study.

OBJECTIVE: To quantify flow irregularities in drug delivery caused by vertical displacement of syringe pumps. METHODS: A bench experiment was performed to quantify the effect of height on pumps used in our intensive care and theatre settings. A standard syringe pump and line set loaded with a dye solution was run through a graduated length of tubing, and the effect of changing pump height quantified by measuring progress down the tubing over time. RESULTS: A 30 cm elevation produced significant drug delivery boluses - up to seven times the programmed rate at 2mL/h. Delivery rate increased in inverse proportion to the programmed rate, as did the time taken to return to the programmed rate. Lowering the pump 30 cm resulted in no-flow times of up to 180 seconds at a flow rate of 2mL/h - again inversely proportional to programmed rate. CONCLUSIONS: Vertical displacement of a common syringe pump by 30 cm produced significant bolus and cessation phenomena. These findings confirm the observations of previous authors and also demonstrate significant flow irregularities with smaller vertical displacements than previously tested. Further testing with other brands of pumps is required before a solution to this clinically important problem may be approached.