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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: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.

Project description:ObjectivesTo characterize the association between pulmonary embolism (PE) severity and bleeding risk with treatment approaches, outcomes, and complications.MethodsSecondary analysis of an 11-hospital registry of adult ED patients treated by a PE response team (August 2016-November 2022). Predictors were PE severity and bleeding risk. The primary outcome was treatment approach: anticoagulation monotherapy vs. advanced intervention (categorized as "immediate" or "delayed" based on whether the intervention was received within 12 hours of PE diagnosis or not). Secondary outcomes were death, clinical deterioration, and major bleeding.ResultsOf the 1832 patients, 139 (7.6%), 977 (53.3%), and 9 (0.5%) were classified as high-risk, intermediate-high, intermediate-low, and low-risk severity, respectively. There were 94 deaths (5.1%) and 218 patients (11.9%) had one or more clinical deterioration events. Advanced interventions were administered to 86 (61.9%), 195 (27.6%), and 109 (11.2%) patients with high-risk, intermediate-high, and intermediate-low severity, respectively.Major bleeding occurred in 61/1440 (4.2%) on ACm versus 169/392 (7.6%) with advanced interventions (p <0.001): bleeding withcatheter-directed thrombolysiswas 19/145 (13.1%) versus 33/154(21.4%) with systemic thrombolysis,p= 0.07. High risk was twice as strong as intermediate-high risk for association with advanced intervention (OR: 5.3 (4.2 and 6.9) vs. 1.9 (1.6 and 2.2)). High risk (OR: 56.3 (32.0 and 99.2) and intermediate-high risk (OR: 2.6 (1.7 and 4.0)) were strong predictors of clinical deterioration. Major bleeding was significantly associated with advanced interventions (OR: 5.2 (3.5 and 7.8) for immediate, 3.3 (1.8 and 6.2)) for delayed, and high-risk PE severity (OR: 3.4 (1.9 and 5.8)).ConclusionsAdvanced intervention use was associated with high-acuity patients experiencing death, clinical deterioration, and major bleeding with a trend towards less bleeding with catheter-directed interventions versus systemic thrombolysis.

Project description:BackgroundThe national early warning score (NEWS) enables early detection of in-hospital patient deterioration and timely activation of hospital's rapid response team (RRT). NEWS was updated in 2017 to include a separate SpO2 scale for those patients with type II respiratory failure (T2RF). In this study we investigated whether NEWS with and without the new SpO2 scale for the T2RF patients is associated with immediate and in-hospital patient outcomes among the patients actually attended by the RRT.MethodsWe conducted a two-year prospective observational study including all adult RRT patients without limitations of medical treatment (LOMT) in a large Finnish university associated tertiary level hospital. According to the first vital signs measured by the RRT, we calculated NEWSs for the RRT patients and further utilized the new SpO2 scale for the patients with confirmed T2RF. We used multivariate logistic regression and area under the receiver operating characteristic analyses to test NEWS's accuracy to predict two distinct outcomes: RRT patient's I) immediate need for intensive care and/or new LOMT and 2) in-hospital death or discharge with cerebral performance category >2 and/or LOMT.ResultsThe final cohort consisted of 886 RRT patients attended for the first time during their hospitalization. Most common reasons for RRT activation were respiratory (343, 39%) and circulatory (226, 26%) problems. Cohort's median (Q1, Q3) NEWS at RRT arrival was 8 (5, 10) and remained unchanged if the new SpO2 scale was applied for the 104 patients with confirmed T2RF. Higher NEWS was independently associated with both immediate (OR 1.28; 95% CI 1.22-1.35) and in-hospital (1.15; 1.10-1.21) adverse outcomes. Further, NEWS had fair discrimination for both the immediate (AUROC 0.73; 0.69-0.77) and in-hospital (0.68; 0.64-0.72) outcomes. Utilizing the new SpO2 scale for the patients with confirmed T2RF did not improve the discrimination capability (0.73; 0.69-0.76 and 0.68; 0.64-0.71) for these outcomes, respectively.ConclusionsWe found that in patients attended by a RRT, the NEWS predicts patient's hospital outcome with moderate accuracy. We did not find any improvement using the new SpO2 scale in T2RF patients.

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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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