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Reduction of in-hospital cardiac arrest with sequential deployment of rapid response team and medical emergency team to the emergency department and acute care wards.

ABSTRACT: Purpose: This study aimed to determine if sequential deployment of a nurse-led Rapid Response Team (RRT) and an intensivist-led Medical Emergency Team (MET) for critically ill patients in the Emergency Department (ED) and acute care wards improved hospital-wide cardiac arrest rates.

Methods: In this single-center, retrospective observational cohort study, we compared the cardiac arrest rates per 1000 patient-days during two time periods. Our hospital instituted a nurse-led RRT in 2012 and added an intensivist-led MET in 2014. We compared the cardiac arrest rates during the nurse-led RRT period and the combined RRT-MET period. With the sequential approach, nurse-led RRT evaluated and managed rapid response calls in acute care wards and if required escalated care and co-managed with an intensivist-led MET. We specifically compared the rates of pulseless electrical activity (PEA) in the two periods. We also looked at the cardiac arrest rates in the ED as RRT-MET co-managed patients with the ED team.

Results: Hospital-wide cardiac arrests decreased from 2.2 events per 1000 patient-days in the nurse-led RRT period to 0.8 events per 1000 patient-days in the combined RRT and MET period (p-value = 0.001). Hospital-wide PEA arrests and shockable rhythms both decreased significantly. PEA rhythms significantly decreased in acute care wards and the ED.

Conclusion: Implementing an intensivist-led MET-RRT significantly decreased the overall cardiac arrest rate relative to the rate under a nurse-led RRT model. Additional MET capabilities and early initiation of advanced, time-sensitive therapies likely had the most impact.

SUBMITTER: Mankidy B

PROVIDER: S-EPMC7707602 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Reduction of in-hospital cardiac arrest with sequential deployment of rapid response team and medical emergency team to the emergency department and acute care wards.

Mankidy Babith B Howard Christopher C Morgan Christopher K CK Valluri Kartik A KA Giacomino Bria B Marfil Eddie E Voore Prakruthi P Ababio Yao Y Razjouyan Javad J Naik Aanand D AD Herlihy James P JP

PloS one 20201201 12

<h4>Purpose</h4>This study aimed to determine if sequential deployment of a nurse-led Rapid Response Team (RRT) and an intensivist-led Medical Emergency Team (MET) for critically ill patients in the Emergency Department (ED) and acute care wards improved hospital-wide cardiac arrest rates.<h4>Methods</h4>In this single-center, retrospective observational cohort study, we compared the cardiac arrest rates per 1000 patient-days during two time periods. Our hospital instituted a nurse-led RRT in 20 ...[more]

PMID: 33259488

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Project description:Emergency Departments (ED) are trying to alleviate crowding using various interventions. We assessed the effect of an alternative model of care, the Medical Team Evaluation (MTE) concept, encompassing team triage, quick registration, redesign of triage rooms and electronic medical records (EMR) on door-to-doctor (waiting) time and ED length of stay (LOS). We conducted an observational, before-and-after study at an urban academic tertiary care centre. On July 17th 2014, MTE was initiated from 9:00 a.m. to 10 p.m., 7 days a week. A registered triage nurse was teamed with an additional senior ED physician. Data of the 5-month pre-MTE and the 5-month MTE period were analysed. A matched comparison of waiting times and ED LOS of discharged and admitted patients pertaining to various Emergency Severity Index (ESI) triage categories was performed based on propensity scores. With MTE, the median waiting times improved from 41.2 (24.8-66.6) to 10.2 (5.7-18.1) minutes (min; P < 0.01). Though being beneficial for all strata, the improvement was somewhat greater for discharged, than for admitted patients. With a reduction from 54.3 (34.2-84.7) to 10.5 (5.9-18.4) min (P < 0.01), in terms of waiting times, MTE was most advantageous for ESI4 patients. The overall median ED LOS increased for about 15 min (P < 0.01), increasing from 3.4 (2.1-5.3) to 3.7 (2.3-5.6) hours. A significant increase was observed for all the strata, except for ESI5 patients. Their median ED LOS dropped by 73% from 1.2 (0.8-1.8) to 0.3 (0.2-0.5) hours (P < 0.01). In the same period the total orders for diagnostic radiology increased by 1,178 (11%) from 10,924 to 12,102 orders, with more imaging tests being ordered for ESI 2, 3 and 4 patients. Despite improved waiting times a decrease of ED LOS was only seen in ESI level 5 patients, whereas in all the other strata ED LOS increased. We speculate that this was brought about by the tendency of triage physicians to order more diagnostic radiology, anticipating that it may be better for the downstream physician to have more information rather than less.

Project description:Background Internationally increasing demand for emergency care is driving innovation within emergency services. The Alternative Pre-Hospital Pathway (APP) Team is one such Community Emergency Medicine (CEM) initiative developed in Cork, Ireland to target low acuity emergency calls. In this paper the inception of the APP Team is described, and an observational descriptive analysis of the APP Team’s service data presented for the first 12 months of operation. The aim of this study is to describe and analyse the APP team service. Methods The APP Team, consisting of a Specialist Registrar (SpR) in Emergency Medicine (EM) and an Emergency Medical Technician (EMT) based in Cork, covers a mixed urban and rural population of approximately 300,000 people located within a 40-min drive time of Cork University Hospital. The team are dispatched to low acuity 112/999 calls, aiming to provide definitive care or referring patients to the appropriate community or specialist service. A retrospective analysis was performed of the team’s first 12 months of operation using the prospectively maintained service database. Results Two thousand and one patients were attended to with a 67.8% non-conveyance rate. The median age was 62 years, with 33.0% of patients aged over 75 years. For patients over 75 years, the non-conveyance rate was 62.0%. The average number of patients treated per shift was 7. Medical complaints (319), falls (194), drug and alcohol related presentations (193), urological (131), and respiratory complaints (119) were the most common presentations. Conclusion Increased demand for emergency care and an aging population is necessitating a re-design of traditional models of emergency care delivery. We describe the Alternative Pre-Hospital Pathway service, delivered by an EMT and an Emergency Medicine SpR responding to low acuity calls. This service achieved a 68% non-conveyance rate; our data demonstrates that a community emergency medicine outreach team in collaboration with the National Ambulance Service offering Alternative Pre-Hospital Pathways is an effective model for reducing conveyances to hospital. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00536-x.

Project description:Importance:The Medicare Hospital Readmissions Reduction Program (HRRP) is associated with reduced readmission rates, but it is unknown how this decrease occurred. Objective:To examine whether the HRRP was associated with changes in the probability of readmission at emergency department (ED) visits after hospital discharge (ED revisits) overall and depending on whether admission is typically indicated for the patient's condition at the ED revisit. Design, Setting, and Participants:This retrospective cohort study used hospital and ED discharge data from California, Florida, and New York from January 1, 2010, to December 31, 2014. A difference-in-differences analysis examined change in readmission probability at ED revisits for recently discharged patients; ED revisits with clinical presentations for which admission is typically indicated vs those for which admission is more variable (ie, discretionary) were examined separately. Inclusion criteria were Medicare patients 65 years and older who revisited an ED within 30 days of inpatient discharge. Data were analyzed from December 18, 2018, to September 11, 2019. Exposures:Before and after HRRP implementation among patients initially hospitalized for targeted vs nontargeted conditions. Main Outcomes and Measures:Thirty-day unplanned hospital readmissions at the ED revisit. Results:A total of 9?914?068 index hospitalizations were identified in California, Florida, and New York from 2010 to 2014. Of 2?052?096 discharges in 2010, 1?168?126 (56.9%) discharges were women and 566?957 discharges (27.6%) were among patients older than 85 years. Among 1?421?407 patients with an unplanned readmission within 30 days of discharge, 1?266?107 patients (89.1%) were admitted through the ED. A total of 1?906?498 ED revisits were identified. After adjusting for patient demographic and clinical characteristics from the index hospitalization, HRRP implementation was associated with fewer readmissions from the ED, with a difference-in-difference estimate of -0.9 (95% CI, -1.4 to -0.4) percentage points (P?<?.001), or a 1.4% relative decrease from the 65.8% pre-HRRP readmission rates. Implementation of the HRRP was associated with fewer readmissions at the ED revisit involving clinical presentations for which admission is typically indicated (difference-in-differences estimate, -1.1 [95% CI, -1.6 to -0.6] percentage points; P?<?.001), or a 1.2% relative decrease from the 93.6% pre-HRRP rate. These results appear to be associated with patients presenting at the ED revisit with congestive heart failure (difference-in-difference estimate, -1.2 [95% CI, -2.0 to -0.4] percentage points; P?=?.003). Conclusions and Relevance:These findings suggest that implementation of the HRRP was associated with a lower likelihood of readmission for recently discharged patients presenting to the ED, specifically for congestive heart failure. This highlights the critical role of the ED in readmission reduction under the HRRP and suggests that patient outcomes after HRRP implementation should be further studied.

Project description:ObjectiveRising emergency medical services (EMS) utilisation increases transport to hospital emergency departments (ED). However, some patients receive outpatient treatment (discharged) while others are hospitalised (admitted). The aims of this analysis were to compare admitted and discharged cases, to assess whether cases that were discharged from the ED could be identified using dispatch data and to compare dispatch keyword categories and hospital diagnoses.DesignRetrospective observational study using linked secondary data.Setting and participants78 303 cases brought to 1 of 14 ED in the city of Munich, Germany, by EMS between 1 July 2013 and 30 June 2014.Main outcome measuresCharacteristics of admitted and discharged cases were assessed. Logistic regression was used to estimate the association between discharge and age, sex, time of day, ambulance type and dispatch keyword category. Keyword categories were compared to hospital diagnoses.Results39.4% of cases were discharged. They were especially likely to be young (OR 10.53 (CI 9.31 to 11.92), comparing <15-year-olds to >70-year-olds) and to fall under the categories 'accidents/trauma' (OR 2.87 (CI 2.74 to 3.01)) or 'other emergencies (unspecified)' (OR 1.23 (CI 1.12 to 1.34) (compared with 'cardiovascular'). Most frequent diagnoses came from chapter 'injury and poisoning' (30.1%) of the 10th revision of the international statistical classification of disease and related health problems (ICD-10), yet these diagnoses were more frequent at discharge (42.7 vs 22.0%) whereas circulatory system disease was less frequent (2.6 vs 21.8%). Except for accidents/trauma and intoxication/poisoning many underlying diagnoses were observed for the same dispatch keyword.ConclusionYoung age and dispatch for accidents or trauma were the strongest predictors of discharge. Even within the same dispatch keyword category the distribution of diagnoses differed between admitted and discharged cases. Discharge from the ED does not indicate that urgent response was unnecessary. However, these cases could be suitable for allocation to hospitals with low inpatient bed capacities and are of particular interest for future studies regarding the urgency of their condition.

Project description:Importance:Emergency medical services (EMS) deliver essential initial care for patients with out-of-hospital cardiac arrest (OHCA), but the extent to which patient outcomes vary between different EMS agencies is not fully understood. Objective:To quantify variation in patient outcomes after OHCA across EMS agencies. Design, Setting, and Participants:This observational cohort study was conducted in the Resuscitation Outcomes Consortium (ROC) Epistry, a prospective multicenter OHCA registry at 10 sites in North America. Any adult with OHCA treated by an EMS from April 2011 through June 2015 was included. Data analysis occurred from May 2017 to March 2018. Exposure:Treating EMS agency. Main Outcomes and Measures:The primary outcome was survival to hospital discharge. Secondary outcomes were return of spontaneous circulation at emergency department arrival and favorable functional outcome at hospital discharge (defined as a modified Rankin scale score ≤3). Multivariable hierarchical logistic regression models were used to adjust confounders and clustering of patients within EMS agencies, and calculated median odds ratios (MORs) were used to quantify the extent of residual variation in outcomes between EMS agencies. Results:We identified 43 656 patients with OHCA treated by 112 EMS agencies. At EMS agency level, we observed large variations in survival to hospital discharge (range, 0%-28.9%; unadjusted MOR, 1.43 [95% CI, 1.34-1.54]), return of spontaneous circulation on emergency department arrival (range, 9.0%-57.1%; unadjusted MOR, 1.53 [95% CI, 1.43-1.65]), and favorable functional outcome (range, 0%-20.4%; unadjusted MOR, 1.54 [95% CI, 1.40-1.73]). This variation persisted despite adjustment for patient-level and EMS agency-level factors known to be associated with outcomes (adjusted MOR for survival 1.56 [95% CI 1.44-1.73]; adjusted MOR for return of spontaneous circulation at emergency department arrival, 1.50 [95% CI, 1.41-1.62]; adjusted MOR for functionally favorable survival, 1.53 [95% CI, 1.37-1.78]). After restricting analysis to those who survived more than 60 minutes after hospital arrival and including hospital treatment characteristics, the variation persisted (adjusted MOR for survival, 1.49 [95% CI, 1.36-1.69]; adjusted MOR for functionally favorable survival, 1.34 [95% CI, 1.20-1.59]). Conclusions and Relevance:We found substantial variations in patient outcomes after OHCA between a large group of EMS agencies in North America that were not explained by documented patient-level and EMS agency-level variables.

Project description:Hospitals often employ Medical Emergency Teams (METs) to respond to patients with acute physiological decline so as to prevent deaths from in-hospital cardiac arrest (IHCA). We determined the frequency of missed opportunities for MET evaluation, defined as no MET evaluation prior to IHCA despite evidence of severe vital sign abnormalities ?1 hour preceding cardiac arrest.Within Get With The Guidelines-Resuscitation, we identified 21,913 patients from 274 hospitals with IHCA on general inpatient or telemetry floors who would be eligible for a MET evaluation prior to IHCA. We determined the proportion of patients with missed opportunities for MET evaluation, defined as no MET evaluation before IHCA despite at least 1 severe vital sign abnormality (pulse >150 or <30, respiratory rate >35 or <8, systolic blood pressure <80, and oxygen saturation <80%) 1, 2, and 4 hours before IHCA. The relationship between a hospital's proportion of missed opportunities for MET evaluation and its risk-standardized rate of survival to discharge for IHCA (derived using hierarchical linear regression models) was then evaluated.Overall, few (3,814 [17.4%]) patients with IHCA had a preceding MET evaluation, and the odds of a MET evaluation varied by >80% across hospitals (median, 14.6% [interquartile range, 9.1%-22.2%]; median odds ratio, 1.82). Vital sign data were available for 13,115 (72.5%) of the 18,099 patients without MET evaluation. Of these patients, 5,243 (40.0%), 4,078 (31.1%), and 1,767 (13.4%) had at least 1 severe vital sign abnormality ?1, 2, and 4 hours before IHCA, respectively. Hospitals with the highest proportion of unevaluated patients despite severe vital sign abnormalities 2 and 4 hours preceding cardiac arrest had the lowest IHCA survival rate (correlation of -0.14 [P = .04] and -0.16 [P = .01], respectively).Although METs are designed to prevent IHCA, many patients with severe vital sign abnormalities prior to IHCA did not have a MET evaluation, and hospitals with higher rates of unevaluated patients had lower IHCA survival. These findings suggest missed opportunities to efficiently use METs in current practice.

Dataset Information

Reduction of in-hospital cardiac arrest with sequential deployment of rapid response team and medical emergency team to the emergency department and acute care wards.

Publications

Reduction of in-hospital cardiac arrest with sequential deployment of rapid response team and medical emergency team to the emergency department and acute care wards.

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