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Association Between Survival and Time of Day for Rapid Response Team Calls in a National Registry.

ABSTRACT: OBJECTIVES:Decreased staffing at nighttime is associated with worse outcomes in hospitalized patients. Rapid response teams were developed to decrease preventable harm by providing additional critical care resources to patients with clinical deterioration. We sought to determine whether rapid response team call frequency suffers from decreased utilization at night and how this is associated with patient outcomes. DESIGN:Retrospective analysis of a prospectively collected registry database. SETTING:National registry database of inpatient rapid response team calls. PATIENTS:Index rapid response team calls occurring on the general wards in the American Heart Association Get With The Guidelines-Medical Emergency Team database between 2005 and 2015 were analyzed. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:The primary outcome was inhospital mortality. Patient and event characteristics between the hours with the highest and lowest mortality were compared, and multivariable models adjusting for patient characteristics were fit. A total of 282,710 rapid response team calls from 274 hospitals were included. The lowest frequency of calls occurred in the consecutive 1 AM to 6:59 AM period, with 266 of 274 (97%) hospitals having lower than expected call volumes during those hours. Mortality was highest during the 7 AM hour and lowest during the noon hour (18.8% vs 13.8%; adjusted odds ratio, 1.41 [1.31-1.52]; p < 0.001). Compared with calls at the noon hour, those during the 7 AM hour had more deranged vital signs, were more likely to have a respiratory trigger, and were more likely to have greater than two simultaneous triggers. CONCLUSIONS:Rapid response team activation is less frequent during the early morning and is followed by a spike in mortality in the 7 AM hour. These findings suggest that failure to rescue deteriorating patients is more common overnight. Strategies aimed at improving rapid response team utilization during these vulnerable hours may improve patient outcomes.

SUBMITTER: Churpek MM

PROVIDER: S-EPMC5600679 | biostudies-literature | 2017 Oct

REPOSITORIES: biostudies-literature

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Association Between Survival and Time of Day for Rapid Response Team Calls in a National Registry.

Churpek Matthew Michael MM Edelson Dana P DP Lee Ji Yeon JY Carey Kyle K Snyder Ashley A

Critical care medicine 20171001 10

<h4>Objectives</h4>Decreased staffing at nighttime is associated with worse outcomes in hospitalized patients. Rapid response teams were developed to decrease preventable harm by providing additional critical care resources to patients with clinical deterioration. We sought to determine whether rapid response team call frequency suffers from decreased utilization at night and how this is associated with patient outcomes.<h4>Design</h4>Retrospective analysis of a prospectively collected registry ...[more]

PMID: 28742548

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Project description:BACKGROUND:Rapid Response Team (RRT) calls are clinical crises. Clinical and time pressures can hinder effective liaison between staff who call the RRT ('users') and those responding as part of the RRT ('members'). Non-technical skills (NTS) training has been shown to improve communication and cooperation but requires time and financial resources that may not be available in acute care hospitals. Rapid Response System (RRS) re-design, aiming to promote use of NTS, may provide an alternative approach to improving interactions within RRTs and between members and users. METHODS:Re-design of an existing mature RRS was undertaken in a tertiary, metropolitan hospital incorporating the addition of: 1) regular RRT meetings 2) RRT role badges and 3) a structured member-to-user patient care responsibility "hand-off" process. To compare experiences and perceptions of calls, users and members were surveyed pre and post re-design. RESULTS:Post re-design there were improvements in members' understanding of RRT roles (P?=?0.03) and responsibilities (P?<?0.01), and recollection of introducing themselves to users (P?=?0.02). For users, after the re-design, there were improvements in identification of the RRT leader (P?<?0.01), and in the development of clinical plans for patients remaining on the ward at the end of an RRT call (P?<?0.01). However, post-re-design, fewer users agreed that the structured hand-off was useful or that they should be involved in the process. Both members and users reported fewer experiences of conflict at RRT calls post-re-design (both P?<?0.01). CONCLUSION:The RRS re-design yielded improvements in interactions between members in RRTs and between RRT members and users. However, some unintended consequences arose, particularly around user satisfaction with the structured hand-off. These findings suggest that refinement and improvement of the RRS is possible, but should be an ongoing iterative effort, ideally supported by staff training. TRIAL REGISTRATION:NCT01551160. Registered: 12th March 2012.

Project description:Clinical deterioration of hospitalized patients is common and can lead to critical illness and death. Rapid response teams (RRTs) assess and treat high-risk patients with signs of clinical deterioration to prevent further worsening and subsequent adverse outcomes. Whether activation of the RRT early in the course of clinical deterioration impacts outcomes, however, remains unclear. We sought to characterize the relationship between increasing time to RRT activation after physiologic deterioration and short-term patient outcomes.DesignRetrospective multicenter cohort study.SettingThree academic hospitals in Pennsylvania.PatientsWe included the RRT activation of a hospitalization for non-ICU inpatients greater than or equal to 18 years old.InterventionsNone.Measurements and main resultsThe primary exposure was time to RRT activation after physiologic deterioration. We selected four Cardiac Arrest Risk Triage (CART) score thresholds a priori from which to measure time to RRT activation (CART score ≥ 12, ≥ 16, ≥ 20, and ≥ 24). The primary outcome was 7-day mortality-death or discharge to hospice care within 7 days of RRT activation. For each CART threshold, we modeled the association of time to RRT activation duration with 7-day mortality using multivariable fractional polynomial regression. Increased time from clinical decompensation to RRT activation was associated with higher risk of 7-day mortality. This relationship was nonlinear, with odds of mortality increasing rapidly as time to RRT activation increased from 0 to 4 hours and then plateauing. This pattern was observed across several thresholds of physiologic derangement.ConclusionsIncreasing time to RRT activation was associated in a nonlinear fashion with increased 7-day mortality. This relationship appeared most marked when using a CART score greater than 20 threshold from which to measure time to RRT activation. We suggest that these empirical findings could be used to inform RRT delay definitions in further studies to determine the clinical impact of interventions focused on timely RRT activation.

Project description:BackgroundHyperoxemia may aggravate reperfusion brain injury after cardiac arrest. The aim of this study was to study the associations between different levels of hyperoxemia in the reperfusion period after cardiac arrest and 30-day survival.MethodsNationwide observational study using data from four compulsory Swedish registries. Adult in- and out-of-hospital cardiac arrest patients admitted to an ICU, requiring mechanical ventilation, between January 2010 and March 2021, were included. The partial oxygen pressure (PaO2) was collected in a standardized way at ICU admission (± one hour) according to the simplified acute physiology score 3 reflecting the time interval with oxygen treatment from return of spontaneous circulation to ICU admission. Subsequently, patients were divided into groups based on the registered PaO2 at ICU admission. Hyperoxemia was categorized into mild (13.4-20 kPa), moderate (20.1-30 kPa) severe (30.1-40 kPa) and extreme (> 40 kPa), and normoxemia as PaO2 8-13.3 kPa. Hypoxemia was defined as PaO2 < 8 kPa. Primary outcome was 30-day survival and relative risks (RR) were estimated by multivariable modified Poisson regression.ResultsIn total, 9735 patients were included of which 4344 (44.6%) were hyperoxemic at ICU admission. Among these, 2217 were classified as mild, 1091 as moderate, 507 as severe, and 529 as extreme hyperoxemia. Normoxemia was present in 4366 (44.8%) patients and 1025 (10.5%) had hypoxemia. Compared to the normoxemia group, the adjusted RR for 30-day survival in the whole hyperoxemia group was 0.87 (95% CI 0.82-0.91). The corresponding results for the different hyperoxemia subgroups were; mild 0.91 (95% CI 0.85-0.97), moderate 0.88 (95% CI 0.82-0.95), severe 0.79 (95% CI 0.7-0.89), and extreme 0.68 (95% CI 0.58-0.79). Adjusted 30-day survival for the hypoxemia compared to normoxemia group was 0.83 (95% CI 0.74-0.92). Similar associations were seen in both out-of-hospital and in-hospital cardiac arrests.ConclusionIn this nationwide observational study comprising both in- and out-of-hospital cardiac arrest patients, hyperoxemia at ICU admission was associated with lower 30-day survival.

Project description:BackgroundRepeat Rapid Response Team (RRT) calls are associated with increased in-hospital mortality risk and pose an organisation-level resource burden. Use of Non-Technical Skills (NTS) at calls has the potential to reduce potentially preventable repeat calling. NTS are usually improved through training, although this consumes time and financial resources. Re-designing the Rapid Response System (RRS) to promote use of NTS may provide a feasible alternative.MethodsA pre-post observational study was undertaken to assess the effect of an RRS re-design that aimed to promote use of NTS during RRT calls. The primary outcome was the proportion of admissions each month subject to repeat RRT calling, and the average number of repeat calls per admission each month was the secondary outcome of interest. Univariate and multivariable interrupted time series analyses compared outcomes between the two study phases.ResultsThe proportion of admissions with repeat calls each month increased across both phases of the study period, but the increase was lower in the post re-design phase (change in regression slope -0.12 (standard error 0.07) post versus pre re-design). The multivariable model predicted a 6% reduction (95% confidence interval -15.1-3.1; P = 0.19) in the proportion of admissions having repeat calls at the end of the post redesign phase study compared to the predicted proportion in the absence of the re-design. The average number of calls per admission was also predicted to decrease in the post re-design phase, with an estimated difference of -0.07 calls per admission (equivalent to one fewer repeat call per 14 patients who had RRT calls) at the end of the post re-design phase (95% confidence interval -0.23-0.08, P = 0.35).ConclusionThis study of an RRS re-design showed modest, but not statistically significant, reductions in the proportion of admissions with repeat calls and the mean number of repeat calls per admission. Given the economic and workforce capacity issues that all health care systems now face, even small improvements in the RRS may have lasting impact across the organisation. For the potential interest of RRS managers, this paper presents a pragmatic, low-cost initiative intended to enhance communication and cooperation at RRT calls.

Dataset Information

Association Between Survival and Time of Day for Rapid Response Team Calls in a National Registry.

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Association Between Survival and Time of Day for Rapid Response Team Calls in a National Registry.

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