Association between time of day for rapid response team activation and mortality.

PURPOSE: To evaluate the frequency of rapid response team (RRT) calls by time of day and their association with in-hospital mortality. MATERIALS AND METHODS: This was a retrospective cohort study of all RRT calls at a tertiary teaching hospital in Porto Alegre, Brazil. Patients were categorized according to the time of initial RRT activation. Activations were classified as daytime (7:00-18:59) or nighttime (19:00-6:59). The primary outcome was in-hospital mortality rate. The secondary outcome was ICU admission within 48 h of RRT assessment. RESULTS: During the study period, 4522 patients were included in the final analysis. Cardiovascular and respiratory changes were more common causes of nighttime activation, whereas neurological and laboratory changes were more common during the daytime. The in-hospital mortality rate was 23.9% (1081/4522). Nighttime RRT calls were not associated with worse outcomes than daytime calls. However, a decrease in the number of calls was observed during nursing handover periods (7:00, 13:00 and 19:00). Two time periods were associated with increased adjusted odds for mortality: 12:00-13:00 (adjusted OR 2.277; 95% CI 1.392-3.725) and 19:00-20:00 (adjusted OR 1.873; CI 1.873; 95% 1.099-3.190). CONCLUSION: We found that nighttime RRT calls were not associated with worse outcomes than daytime RRT calls. However, a decrease in the number of calls and higher mortality was observed during nursing handover periods.

The Quality of End-of-Life Care after Limitations of Medical Treatment as Defined by a Rapid Response Team: A Retrospective Cohort Study.

BACKGROUND: Despite the increase in the identification of patients at the end of life after the introduction of rapid response team (RRT), there is doubt as to whether there has been an improvement in the quality of care offered to these patients. Proper end-of-life care is the next expected step after identifying patients who are dying. OBJECTIVE: To evaluate the end-of-life care after limitations of medical treatment (LOMTs) as defined by an RRT. DESIGN: This is a single-center retrospective cohort study at a tertiary teaching hospital in Porto Alegre, Brazil, from July 2014 to July 2016. SETTING/SUBJECTS: We included 242 patients with an LOMT as defined by the RRT. MEASUREMENTS: Outcomes of interest included symptoms and palliative measures after RRT review. RESULTS: During the study period, there were 5396 calls to 2937 patients, representing 126 calls per 1000 hospital discharges. Of these calls, 4.9% (n = 242) resulted in an LOMT. The primary care team agreed with the LOMT decision proposed by the RRT in 91.7% of cases. Regarding end-of-life symptoms, 7.4% and 5.8% of patients presented with intense or moderate pain, respectively, and 62.4% of patients presented dyspnea in the last 48 hours of hospitalization. Less than 15% of patients received attention for their spiritual needs and/or received psychological support. CONCLUSIONS: Our data reinforce the important role of RRTs in the identification of end-of-life patients with clinical deterioration. Despite the increase in the identification of these patients, the quality of end-of-life care needs to be improved.

Delayed medical emergency team calls and associated outcomes.

OBJECTIVE: To determine whether there was an association between delayed medical emergency team calls and mortality after a medical emergency team review. DESIGN: This was a prospective observational study. SETTING: A university-affiliated tertiary referral hospital in Porto Alegre, Brazil. PATIENTS: All patients were reviewed by the medical emergency team from July 2008 to December 2009. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 1,481 calls for 1,148 patients. Delayed medical emergency team calls occurred for 246 patients (21.4%). The criterion associated with delay was typically the same criterion for the subsequent medical emergency team call. Physicians had a greater prevalence of delayed medical emergency team calls (110 of 246 [44.7%]) than timely medical emergency team calls (267 of 902 [29.6%]; p < 0.001). The mortality at 30 days after medical emergency team review was higher among patients with delayed medical emergency team activation (152 [61.8%]) than patients receiving timely medical emergency team activation (378 [41.9%]; p < 0.001). In a multivariate analysis, delayed medical emergency team calls remained significantly associated with higher mortality. CONCLUSIONS: Delayed medical emergency team calls are common and are independently associated with higher mortality. This result reaffirms the concept and need for a rapid response system.

[Safety and health in workers employed in industry. Data from Industrial Accidents Compensation Board (INAIL) and National Social Security Institute (INPS), Veneto Region, 1994-2002]. / Sicurezza e salute dei lavoratori dell'Industria attraverso i dati INAIL e INPS, Veneto, 1994-2002.

BACKGROUND: A decreasing time trend for occupational injuries and sickness absence would be the effect of the new legislation (D.Lgs. 626/94 and successive laws) on prevention in occupational settings. Conversely, the reduction of INPS disability would reflect a health improvement due to non-occupational causes. OBJECTIVES: The aim of the study was to investigate the efficacy of the new legislation among employees in industry (where the law was mainly applied), via the time trend of three standardized rates in the Veneto Region. METHODS: The numerator for the rate of occupational accidents (cases occurring in industry workers in the Veneto Region, broken down for sex, age and calendar years) was supplied by INAIL. The denominator for the above rate, as well as numerators and denominators for disability and sickness absence were supplied by INPS. Data were available from 1994 to 2002 for accidents and disability, and from 1997 to 2002 for sickness absence. In every year from 1994 to 2002, the rates were standardized for age and sex with the direct method, using an internal "standard" population. The time trend of year-specific standardized rates was analyzed by Joinpoint regression software. RESULTS: Among industrial workers in the Veneto Region, occupational accidents increased by 0.4% yearly, while disability decreased by 2.56% from 1994 to 2002. Sick absence increased up to 1999, then decreased. CONCLUSIONS: This epidemiological pattern is difficult to explain. The increase in accidents could be due to the increase of non-European Union workers and/or to the fact that accidents on the way to or from work were recognized as occupational accidents by INAIL starting from 2000. Both these phenomena could have contributed to increase the rate that was otherwise diminishing. On the other hand, this same situation could be due to insufficient efficacy of the legislation (D.Lgs. 626/94 and successive laws) for preventing occupational accidents and diseases.

O médico e o paciente suicida / Physicians and suicidal patients

O suicídio é uma emergência médica presente na prática clínica, sendo importante e necessário que todos os médicos tenham conhecimentos básicos sobre o tema. Os autores revisam a literatura médica com o objetivo de ampliar a compreensão acerca das causas e fatores de risco do suicídio, abrangendo fatores genéticos, ambientais, sociais, epidemiológicos e neurológicos. Trata também do manejo e das atitudes contratransferenciais do médico em relação a tal paciente