Variations in Code Team Composition During Different Times of Day and Week and by Level of Hospital Complexity.

BACKGROUND: Previous data demonstrated lower survival rates of in-hospital cardiac arrests during nights and weekends compared to weekday daytime. This study aimed to evaluate variations of personnel attending to codes based on day/night/weekend conditions within the US Veterans Affairs (VA) system, as well as variations of personnel responsible for intubations during codes. METHODS: Hospital leaders were surveyed regarding code team membership, leadership, and intubations during four time periods (weekday daytime, weekday nighttime, weekend daytime, and weekend nighttime). RESULTS: Surveys were completed for 93 of 123 eligible VA hospitals (response rate of 75.6%). Code teams were significantly smaller during "off-hours." Membership in code teams during regular vs. off-hours was significantly greater for ICU physicians (44.1% vs. 7.5%-15.0%, p < 0.001), anesthesiologists (34.4% vs. 12.9%, p < 0.001), and pharmacists (46.2% vs. 23.7%-26.9%, p < 0.01). Significant differences were found for codes led by ICU attendings (20.4% vs. 5.4%-7.5%, p < 0.05) and intubations performed by ICU attendings (21.5% vs. 6.5%-10.8%, p < 0.05). ICU-based physicians were team leaders more often in high-complexity hospitals (19.7%-50.0% vs. 0%-14.8%), while hospitalists led the majority in the low-complexity hospitals (28.8%-39.4% vs. 63.0%-70.4%). ICU physicians had significantly less involvement in code intubations in low-complexity hospitals (6.1%-22.7% vs. 3.7%-18.5%), while respiratory therapists took on most of this responsibility in low-complexity hospitals and particularly at night. CONCLUSION: This study found significant differences in code team composition, leadership, and intubation responsibilities between regular and off-hours. Low-complexity hospitals, which are generally rural, had team compositions and responsibilities that were visibly different from higher-complexity hospitals.

Mortality of Patients Requiring Escalation to Intensive Care within 24 Hours of Admission in a Mixed Medical-Surgical Population.

OBJECTIVE: Delayed intensive care unit (ICU) admissions are associated with increased mortality. We present a retrospective study looking at whether indirect admissions to the ICU within 24 hours of hospital admission were associated with increased mortality. DESIGN: Retrospective cohort study SETTING: Mixed medical-surgical ICU at a large tertiary United States Veterans Affairs (VA) Hospital System POPULATION: The patients were a mix of medical and surgical patients. Patients included both those directly admitted from the operating room as well as those escalated to the ICU after initial admission to the ward (indirect admission). METHODS: All admissions to a medical-surgical ICU from 2008 to 2013 were included in the study. The database was queried for time and location where the admission originated. Separate lists were created for patients with severe sepsis, patients who transferred to the ICU within the first 24 hours, and patients who had rapid response or code team activations. Analysis was applied to the whole group and to medical and surgical subpopulations. RESULTS: A total of 3,862 ICU admissions were studied. Univariate analysis indicated an impact of delayed admission on whole group and surgical patients; however, multivariate analysis indicated a significant effect of delayed admission on 1-year surgical mortality. Multivariate analysis also showed a consistent effect of age, ICU length of stay, and cardiac arrest on mortality of both medical and surgical ICU patients. CONCLUSION: In a large retrospective study, surgical patients had increased 1-year mortality if they required escalation to the ICU within 24 hours of hospital admission. This result was not replicated in medical patients, possibly related to a burden of illness that could not be altered by earlier care.

Quality metrics for the evaluation of Rapid Response Systems: Proceedings from the third international consensus conference on Rapid Response Systems.

BACKGROUND: Clinically significant deterioration of patients admitted to general wards is a recognized complication of hospital care. Rapid Response Systems (RRS) aim to reduce the number of avoidable adverse events. The authors aimed to develop a core quality metric for the evaluation of RRS. METHODS: We conducted an international consensus process. Participants included patients, carers, clinicians, research scientists, and members of the International Society for Rapid Response Systems with representatives from Europe, Australia, Africa, Asia and the US. Scoping reviews of the literature identified potential metrics. We used a modified Delphi methodology to arrive at a list of candidate indicators that were reviewed for feasibility and applicability across a broad range of healthcare systems including low and middle-income countries. The writing group refined recommendations and further characterized measurement tools. RESULTS: Consensus emerged that core outcomes for reporting for quality improvement should include ten metrics related to structure, process and outcome for RRS with outcomes following the domains of the quadruple aim. The conference recommended that hospitals should collect data on cardiac arrests and their potential predictability, timeliness of escalation, critical care interventions and presence of written treatment goals for patients remaining on general wards. Unit level reporting should include the presence of patient activated rapid response and metrics of organizational culture. We suggest two exploratory cost metrics to underpin urgently needed research in this area. CONCLUSION: A consensus process was used to develop ten metrics for better understanding the course and care of deteriorating ward patients. Others are proposed for further development.

The association of clinical frailty with outcomes of patients reviewed by rapid response teams: an international prospective observational cohort study.

BACKGROUND: Frailty is a state of vulnerability to poor resolution of homeostasis after a stressor event and is strongly associated with adverse outcomes. Therefore, the assessment of frailty may be an essential part of evaluation in any healthcare encounter that might result in an escalation of care. The purpose of the study was to assess the frequency and association of frailty with clinical outcomes in patients subject to rapid response team (RRT) review. METHODS: In this multi-national prospective observational cohort study, centres with existing RRTs collected data over a 7-day period, with follow up of all patients at 24 h following their RRT call and at hospital discharge or 30 days following the event trigger (whichever came sooner). Investigators also collected data on the triggers and interventions provided and a bedside assessment on the level of patients' frailty using a clinical frailty scale. RESULTS: Amongst 1133 patients, 40% were screened as frail, which was associated with older age (p < 0.001), admission under a medical speciality (p < 0.001), increased severity of illness at the time of the RRT review (p = 0.0047), and substantially higher frequency of limitations of care (p < 0.001). Importantly, 72% of patients screened as frail were either dead or dependent on hospital care by 30 days (p < 0.001). In the multivariable analysis, the significant risk factors for the composite endpoint "poor recovery" (died or were hospital-dependent by 30 days) were age (odds ratio (OR), 1.04; 95% confidence interval (CI), 1.03-1.05; p < 0.001), frailty level (p < 0.001), existing limitation of care (OR, 2.0; 95% CI, 1.3-3.0; p < 0.001), and the quick sequential organ failure assessment (qSOFA) score (p < 0.001). CONCLUSIONS: Higher frailty scores were associated with increased mortality and dependence on health care at 30 days. Our results indicate that frailty has an influence on the clinical trajectory of deteriorating patients and that such assessment should be included in discussion of goals and expectations of care. TRIAL REGISTRATION: Netherlands Trial Registry, NTR5535 . Registered on 23 December 2015.

A Novel Bedside-Focused Ward Surveillance and Response System.

BACKGROUND: Rapid response systems (RRSs) have been universally adopted in much of the developed world; yet, despite broad implementation, their success has often been limited. Even with successful systems, there is a small body of evidence regarding effective organizational elements that are responsible for improved outcomes. New organizational processes were implemented that restructured the existing RRS, and the impact on the number of rapid response team (RRT) alerts, cardiac arrest, and mortality rates was evaluated. METHODS: A prospective five-year before-and-after comparison of adult ward patient outcomes was conducted at a community regional medical center. The key intervention was expanded administrative oversight of the system, which led to (1) restructuring the content and depth of ward nurse education regarding early recognition of at-risk patients; (2) system changes empowering prompt mobilization of the RRT; (3) development of RRT treatment protocols; and (4) a more frequent and comprehensive data collection and analysis for system compliance and performance improvement. RESULTS: Some 28,914 patients were observed in the 24-month control period, and 39,802 patients were observed in the 33-month intervention period. RRT activations increased from 10.2 to 48.8/1,000 discharges (p <0.001), ward cardiac arrest decreased from 3.1 to. 2.4/1000 discharges (p = 0.04), hospital mortality decreased from 3.8% to 3.2% (p <0.001), and the observed-to-expected ratio decreased from 1.5 to 1.0 (p <0.001). CONCLUSION: Expanded administrative involvement of an existing RRS that focused on early recognition of patient deterioration by the bedside nurse led to improved performance of the system, with a significant increase in number of RRTs and decreases in cardiac arrests and hospital mortality.

Clinical outcomes of patients seen by Rapid Response Teams: A template for benchmarking international teams.

AIM: The study was developed to characterize short-term outcomes of deteriorating ward patients triggering a Rapid Response Team (RRT), and describe variability between hospitals or groups thereof. METHODS: We performed an international prospective study of Rapid Response Team (RRT) activity over a 7-day period in February 2014. Investigators at 51 acute hospitals across Australia, Denmark, the Netherlands, USA and United Kingdom collected data on all patients triggering RRT review concerning the nature, trigger and immediate outcome of RRT review. Further follow-up at 24h following RRT review focused on patient orientated outcomes including need for admission to critical care, change in limitations of therapy and all cause mortality. RESULTS: We studied 1188 RRT activations. Derangement of vital signs as measured by the National Early Warning Score (NEWS) was more common in non-UK hospitals (p=0.03). Twenty four hour mortality after RRT review was 10.1% (120/1188). Urgent transfer to ICU or the operating theatre occurred in 24% (284/1188) and 3% (40/1188) of events, respectively. Patients in the UK were less likely to be admitted to ICU (31% vs. 22%; p=0.017) and their median (IQR) time to ICU admission was longer [4.4 (2.0-11.8) vs. 1.5 (0.8-4.4)h; p<0.001]. RRT involvement lead to new limitations in care in 28% of the patients not transferring to the ICU; in the UK such limitations were instituted in 21% of patients while this occurred in 40% of non-UK patients (p<0.001). CONCLUSION: Among patients triggering RRT review, 1 in 10 died within 24h; 1 in 4 required ICU admission, and 1 in 4 had new limitations in therapy implemented. We provide a template for an international comparison of outcomes at RRT level.

Evaluating the Impact of Classroom Education on the Management of Septic Shock Using Human Patient Simulation.

BACKGROUND: Classroom lectures are the mainstay of imparting knowledge in a structured manner and have the additional goals of stimulating critical thinking, lifelong learning, and improvements in patient care. The impact of lectures on patient care is difficult to examine in critical care because of the heterogeneity in patient conditions and personnel as well as confounders such as time pressure, interruptions, fatigue, and nonstandardized observation methods. METHODS: The critical care environment was recreated in a simulation laboratory using a high-fidelity mannequin simulator, where a mannequin simulator with a standardized script for septic shock was presented to trainees. The reproducibility of this patient and associated conditions allowed the evaluation of "clinical performance" in the management of septic shock. In a previous study, we developed and validated tools for the quantitative analysis of house staff managing septic shock simulations. In the present analysis, we examined whether measures of clinical performance were improved in those cases where a lecture on the management of shock preceded a simulated exercise on the management of septic shock. The administration of the septic shock simulations allowed for performance measurements to be calculated for both medical interns and for subsequent management by a larger resident-led team. RESULTS: The analysis revealed that receiving a lecture on shock before managing a simulated patient with septic shock did not produce scores higher than for those who did not receive the previous lecture. This result was similar for both interns managing the patient and for subsequent management by a resident-led team. CONCLUSIONS: We failed to find an immediate impact on clinical performance in simulations of septic shock after a lecture on the management of this syndrome. Lectures are likely not a reliable sole method for improving clinical performance in the management of complex disease processes.

Understanding Decision Making in Critical Care.

BACKGROUND: Human decision making involves the deliberate formulation of hypotheses and plans as well as the use of subconscious means of judging probability, likely outcome, and proper action. RATIONALE: There is a growing recognition that intuitive strategies such as use of heuristics and pattern recognition described in other industries are applicable to high-acuity environments in medicine. Despite the applicability of theories of cognition to the intensive care unit, a discussion of decision-making strategies is currently absent in the critical care literature. CONTENT: This article provides an overview of known cognitive strategies, as well as a synthesis of their use in critical care. By understanding the ways by which humans formulate diagnoses and make critical decisions, we may be able to minimize errors in our own judgments as well as build training activities around known strengths and limitations of cognition.

Routine postoperative care of patients undergoing coronary artery bypass grafting on cardiopulmonary bypass.

The postoperative course of a patient undergoing cardiac surgery (CS) is dictated by a largely predictable set of interactions between disease-specific and therapeutic factors. ICU personnel need to quickly develop a detailed understanding of the patient's current status and how critical care resources can be used to promote further recovery and eventual independence from external support. The goal of this article is to describe a typical operative and postoperative course, with emphasis on the latter, and the diagnostic and therapeutic options necessary for the proper care of these patients. This paper will focus on coronary artery bypass grafting as a model for understanding the course of CS patients; however, many of the principles discussed are applicable to most cardiac surgery patients.

Percutaneous tracheostomy at the bedside: 13 tips for improving safety and success.

We have developed a set of routines and practices in the course of performing a large series (n = 70) of percutaneous dilational tracheostomy (PDT). The 13 tips discussed in this review fall into 4 categories. System factors that facilitate training, patient safety, and avoidance of crises including the use of appropriate personnel, importance of timing, use of premedication, and the utility and content of a preprocedure briefing. Suggestions to prevent loss of the airway include tips on airway assessment, preparation of airway equipment, and use of exchange catheter techniques. Strategies to avoid and manage both microvascular and large-vessel bleeding are discussed. We also discuss the management of common postprocedure problems including tracheostomy tube obstruction, malposition requiring tube exchange or replacement, and air leak. The practical considerations for successful execution of PDT involve common sense, thorough planning, and structured approaches to prevent adverse effects if the procedure does not go as smoothly as expected. These strategies will aid anesthesiologists and intensivists in improving their comfort level, safety, and competence in performing this beside procedure.

An institutionwide approach to redesigning management of cardiopulmonary resuscitation.

BACKGROUND: Despite widespread training in basic life support (BLS) and advanced cardiovascular life support (ACLS) among hospital personnel, the likelihood of survival from in-hospital cardiac arrests remains low. In 2006 a university-affiliated tertiary medical center initiated a cardiopulmonary (CPR) resuscitation redesign project. REDESIGNING THE HOSPITAL'S RESUSCITATION SYSTEM: The CPR Committee developed the interventions on the basis of a large-scale view of the process of delivering BLS and ACLS, identification of key decision nodes and actions, and compartmentalization of specific functions. It was proposed that arrest management follow a steady progression in a two-layer scheme from BLS to ACLS. Handouts describing team structure and specific roles were given to all code team providers and house staff at the start of their month-long rotations. To further increase role clarity and team organization, daily morning and evening meetings of the arrest team were instituted. Site-specific BLS training, on-site ACLS refresher training, and defibrillator training were initiated. Project elements also included use of unannounced mock codes to provide system oversight; preparation and distribution of cognitive aids (printed algorithms, dosing guides, and other checklists to ensure compliance with ACLS protocols), identification of patients who may be unstable or a source of concern, event review and analysis of arrests and other critical events, and a CPR website. CONCLUSION: A mature hospital-based resuscitation system should include definition of arrest trends and resuscitation needs, development of local methods for approaching the arresting patient, an emphasis on prevention, establishment of training programs tailored to meet specific hospital needs, system examination and oversight, and administrative processes that maximize interaction between all components.

The pharmacology of airway management in critical care.

This review provides an update on the pharmacology of airway management, emphasizing medications and management strategies widely used in an intensive care unit setting. Induction agents, muscle relaxants, opioids, sedative-hypnotics, and adjunctive agents are reviewed in the context of emergent airway management. Throughout this review, we emphasize the utility of considering a broad set of pharmacologic agents and approaches for airway management of the critically ill patient.

The evolving role of preoperative testing in vascular surgery patients: can a little knowledge be dangerous?

It has been traditionally recommended that candidates for vascular surgery receive noninvasive stress perfusion testing risk stratification to help decide which patients may benefit from coronary artery revascularization. Recent clinical trials have contested the efficacy of revascularization in this population as well as the information yield of noninvasive testing. This article reviews a number of these studies that are likely to change our beliefs regarding testing and subsequent interventions as well as evolving role of medical therapy in patients undergoing vascular surgery.

Introduction of a rapid response system at a United States veterans affairs hospital reduced cardiac arrests.

BACKGROUND: We sought to determine the impact of a rapid response system on cardiac arrest rates and mortality in a United States veteran population. METHODS: We describe a prospective analysis of cardiac arrests in 9 months before and 27 months after institution of a rapid response system, and retrospective analysis of mortality 3.5 years before the intervention and 27 months after the intervention. The study included all inpatients from a university-affiliated United States Veterans Affairs Medical Center, before and after implementation of a rapid response system, including an educational program, patient calling criteria, and a physician-led medical emergency team. Primary end points were hospital-wide cardiac arrests and mortality rates normalized to hospital discharges. Comparisons of event rates between various time points during the implementation process were made by analysis of variance. RESULTS: Three hundred seventy-eight calls were made to the medical emergency team in the time period studied. Compared with preintervention time points, cardiac arrests were reduced by 57%, amounting to a reduction of 5.6 cardiac arrests per 1000 hospital discharges (P < 0.01). Mortality was reduced during the intervention, but this was attributable to a natural decrease occurring over all phases of the study. CONCLUSIONS: A significant reduction in the rate of cardiac arrests was realized with this intervention, as well as a trend toward lower mortality. We estimate that 51 arrests were prevented in the timeframe studied. Our results suggest that further reductions in morbidity can be realized by expansion of rapid response systems throughout the Veterans Affairs network.

Using in situ simulation to improve in-hospital cardiopulmonary resuscitation.

BACKGROUND: There is widespread recognition that the conduct of cardiac resuscitation is problematic. In situ simulation has been used to train and evaluate cardiac arrest teams' performance in the hospital setting, but in work at a university-affiliated, tertiary care facility, the simulated cardiac arrests were used to understand how well health care providers and their environment function during arrests, with the goal of a rapid intervention to correct problem areas. Latent conditions--innate, mostly hidden, workplace factors--can have a large detrimental impact on resuscitation efforts. METHODS: Observations from a series of unannounced simulated cardiac arrests undertaken at diverse locations within a university-affiliated, tertiary care hospital were a component of an ongoing initiative to improve performance of emergency cardiovascular care. RESULTS: Fourteen cardiac arrest simulations revealed 24 hazardous findings, approximately two thirds of which had a high likelihood of compromising patient survival if they had occurred during an actual cardiac arrest. Categories of problems included active errors by teams and individuals and systemic or latent errors of the environment. Because the simulations were designed with the goal of discovering and documenting errors, most errors led to further actions, policies, and procedures that were rapidly adopted by the medical center to prevent their recurrence. CONCLUSIONS: In situ simulation of cardiac arrests elicits lifelike behaviors and allows engagement of all personnel and resources applicable to real arrests. This method allowed for remedial plans to be developed before further harm could occur. Accordingly, in situ simulation of high-risk events may be a useful, efficient technique that complements existing quality assurance processes in hospitals.

A controllable patient monitor for classroom video projectors.

INTRODUCTION: Moderate capability simulators such as Laerdal's SimMan allow for the operator to control the vital signs presented on the monitor. However, the presence of the mannequin simulator may not always be needed to achieve specific teaching goals. In this report, we describe the use of the SimMan software to generate, control, and project vital signs on a projector screen, with an appearance identical to that of its normal companion monitor. METHODS: We connected a laptop computer running Laerdal's SimMan software to a video projection system through a VGA or S-video connection and were able to create a controllable monitor that could be used for tabletop simulation sessions. RESULTS: We were able to create an interactive and dynamic patient monitor that could be projected to a large group to facilitate tabletop simulation utilizing the Laerdal SimMan software and an external projection screen setup. CONCLUSIONS: Laerdal SimMan software can be used to create a dynamic and interactive presentation tool for classroom learning.