Evaluating implementation of a rapid response team: considering alternative outcome measures.

OBJECTIVE: Determine the prolonged effect of rapid response team (RRT) implementation on failure to rescue (FTR). DESIGN: Longitudinal study of institutional performance with control charts and Bayesian change point (BCP) analysis. SETTING: Two academic hospitals in Midwest, USA. PARTICIPANTS: All inpatients discharged between 1 September 2005 and 31 December 2010. INTERVENTION: Implementation of an RRT serving the Mayo Clinic Rochester system was phased in for all inpatient services beginning in September 2006 and was completed in February 2008. MAIN OUTCOME MEASURE: Modified version of the AHRQ FTR measure, which identifies hospital mortalities among medical and surgical patients with specified in-hospital complications. RESULTS: A decrease in FTR, as well as an increase in the unplanned ICU transfer rate, occurred in the second-year post-RRT implementation coinciding with an increase in RRT calls per month. No significant decreases were observed pre- and post-implementation for cardiopulmonary resuscitation events or overall mortality. A significant decrease in mortality among non-ICU discharges was identified by control charts, although this finding was not detected by BCP or pre- vs. post-analyses. CONCLUSIONS: Reduction in the FTR rate was associated with a substantial increase in the number of RRT calls. Effects of RRT may not be seen until RRT calls reach a sufficient threshold. FTR rate may be better at capturing the effect of RRT implementation than the rate of cardiac arrests. These results support prior reports that short-term studies may underestimate the impact of RRT systems, and support the need for ongoing monitoring and assessment of outcomes to facilitate best resource utilization.

A prospective, randomized trial of an emergency department observation unit for acute onset atrial fibrillation.

STUDY OBJECTIVE: An emergency department (ED) observation unit protocol for the management of acute onset atrial fibrillation is compared with routine hospital admission and management. METHODS: Adult patients presenting to the ED with atrial fibrillation of less than 48 hours' duration without hemodynamic instability or other comorbid conditions requiring hospitalization were enrolled. Participants were randomized to either ED observation unit care or routine inpatient care. The ED observation unit protocol included pulse rate control, cardiac monitoring, reassessment, and electrical cardioversion if atrial fibrillation persisted. Patients who reverted to sinus rhythm were discharged with a cardiology follow-up within 3 days, whereas those still in atrial fibrillation were admitted. All cases were followed up for 6 months and adverse events recorded. RESULTS: Of the 153 patients, 75 were randomized to the ED observation unit and 78 to routine inhospital care. Eighty-five percent of ED observation unit patients converted to sinus rhythm versus 73% in the routine care group (difference 12%; 95% confidence interval [CI] -1% to 25%]; P=.06). The median length of stay was 10.1 versus 25.2 hours (difference 15.1 hours; 95% CI 11.2 to 19.6; P<.001) for ED observation unit and inhospital care respectively. Nine ED observation unit patients required inpatient admission. Eleven percent of the ED observation unit group had recurrence of atrial fibrillation during follow-up versus 10% of the routine inpatient care group (difference 1%; 95% CI -9% to 11%; P=.93). There was no significant difference between the groups in the frequency of hospitalization or the number of tests, and the number of adverse events during follow-up was similar in the 2 groups. CONCLUSION: An ED observation unit protocol that includes electrical cardioversion is a feasible alternative to routine hospital admission for acute onset of atrial fibrillation and results in a shorter initial length of stay.

Quitline referral vs. self-help manual for tobacco use cessation in the Emergency Department: a feasibility study.

BACKGROUND: Tobacco use counseling interventions delivered in the primary care setting are efficacious, but limited evidence exists regarding their feasibility or efficacy in the Emergency Department (ED). ED randomized controlled trials evaluating referral for outpatient tobacco use counseling have not had a single subject in the intervention groups attend scheduled clinic appointments. Telephone counseling potentially affords the opportunity to provide this population with individual counseling more conveniently than traditional clinic counseling. The purpose of this preliminary study was to evaluate the intervention completion rate among cigarette smokers enrolled through the ED in a tobacco quitline (QL) and to assess the feasibility of a randomized controlled trial assessing the efficacy of this intervention. METHODS: We conducted a prospective, randomized, controlled, un-blinded pilot study enrolling cigarette smokers presenting to a tertiary-care ED. Patients indicating a desire to quit smoking were randomized to receive either proactive telephone counseling through a QL (intervention) or a self-help manual (control). RESULTS: Of 212 smokers who indicated an interest in quitting, 20 subjects were randomized to the QL and 19 to control. Twenty-one did not meet inclusion criteria and 152 refused to participate. A total of 10 patients (50%) enrolled in the QL completed the full intervention. However, only a total of 20 patients (51%) were reached for follow-up at 3 or 6 months (10 in each arm). At 6-month follow-up a total of six subjects had either disconnected their phone, no longer lived at the provided phone number or had provided an incorrect number. Two declined to provide follow-up and the remainder could not be reached. Assuming all patients unavailable for follow-up were still smoking, the 7-day point prevalence smoking abstinence rate at 6 months was 20% (95% CI: 6 to 44%) for the QL group and 0% (95% CI: 0 to 15%) for the control group (p = 0.11). CONCLUSION: Compliance with the QL intervention was encouraging and may hold promise for providing needed tobacco use counseling to ED patients. Future studies are required, and should focus on more effective mechanisms to obtain outcome measures and a larger sample size.