Clinical emergencies and outcomes in patients admitted to a surgical versus medical service (original) (raw)
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Resuscitation, 2014
Aims: To compare clinical outcomes between a teaching hospital with a mature rapid response system (RRS), with three similar teaching hospitals without a RRS in Sydney, Australia. Methods: For the period 2002-2009, we compared a teaching hospital with a mature RRS, with three similar teaching hospitals without a RRS. Two non-RRS hospitals began implementing the system in 2009 and a third in January 2010. We compared the rates of in-hospital cardiopulmonary arrest (IHCA), IHCA-related mortality, overall hospital mortality and 1-year post discharge mortality after IHCA between the RRS hospital and the non-RRS hospitals based on three separate analyses: (1) pooled analysis during 2002-2008; (2) before-after difference between 2008 and 2009; (3) after implementation in 2009. Results: During the 2002-2008 period, the mature RRS hospital had a greater than 50% lower IHCA rate, a 40% lower IHCA-related mortality, and 6% lower overall hospital mortality. Compared to 2008, in their first year of RRS (2009) two hospitals achieved a 22% reduction in IHCA rate, a 22% reduction in IHCArelated mortality and an 11% reduction in overall hospital mortality. During the same time, the mature RRS hospital showed no significant change in those outcomes but, in 2009, it still achieved a crude 20% lower IHCA rate, and a 14% lower overall hospital mortality rate. There was no significant difference in 1-year post-discharge mortality for survivors of IHCA over the study period. Conclusions: Implementation of a RRS was associated with a significant reduction in IHCA, IHCA-related mortality and overall hospital mortality.
Resuscitation, 2010
Objective: To evaluate the impact of Rapid Response System (RRS) maturation on delayed Medical Emergency Team (MET) activation and patient characteristics and outcomes. Design: Observational study. Setting: Tertiary hospital. Patients: Recent cohort of 200 patients receiving a MET review and early control cohort of 400 patients receiving a MET review five years earlier at the start of RRS implementation. Measurements and results: We obtained information including demographics, clinical triggers for and timing of MET activation in relation to the first documented MET review criterion (activation delay) and patient outcomes. We found that patients in the recent cohort were older, more likely to be surgical and to have Not For Resuscitation (NFR) orders before MET review. Furthermore, fewer patients (22.0% vs. 40.3%, p < 0.001) had delayed MET activation. When delayed activation occurred, there was a non-significant difference in its duration (early cohort: 12.0 [IQR 23.0] h vs. recent cohort: 9.0 [IQR 20.5] h, p = 0.554). Similarly, unplanned ICU admissions decreased from 31.3% to 17.3% (p < 0.001). Delayed MET activation was independently associated with greater risk of unplanned ICU admission and hospital mortality (O.R. 1.79, 95% C.I. 1.33.-2.93, p = 0.003 and O.R. 2.18, 95% C.I. 1.42-3.33, p < 0.001, respectively). Being part of the recent cohort was independently associated with a decreased risk of delayed activation (O.R. 0.45, 95% C.I. 0.30-0.67, p < 0.001) and unplanned ICU admission (O.R. 0.5, 95% C.I. 0.32-0.78, p = 0.003).
Rapid Response Systems: how to interpret levels of evidence
Clinical Management Issues, 2017
BACKGROUND AND AIM: The Rapid Response System (RRS) has been introduced to prevent cardiac arrest, unplanned admissions to the intensive care unit, and death in hospitalized patients. Despite the constant and widespread presence of this system in worldwide hospitals, it remains debated whether its use improves patient outcomes. The aim of this narrative review is to describe the available evidence supporting the effectiveness of RRSs and to discuss the controversies on the lack of level 1 evidence studies. METHODS: The literature search covers the period from 1 January 2000 to 31 March 2016. RESULTS: Studies with different research designs, observational, quasi-experimental with non-randomized control group and experimental, and aggregate data of meta-analyses indicate a statistically significant reduction of in-hospital cardiac arrests and hospital mortality associated with the deployment of RRSs. CONCLUSIONS: A RRS is a complex intervention in a complex system, such as a hospital. This complexity does not allow considering experimental trials only as the most appropriate methodology to answer at research objectives. Furthermore, the benefits of a RRS depend greatly on its proper use. Accumulating evidence suggests the importance to investigate barriers and facilitators that can affect the integration, within a hospital, of this complex intervention.
Resuscitation, 2016
The study was developed to characterize short-term outcomes of deteriorating ward patients triggering a Rapid Response Team (RRT), and describe variability between hospitals or groups thereof. Methods: We performed an international prospective study of Rapid Response Team (RRT) activity over a 7-day period in February 2014. Investigators at 51 acute hospitals across Australia, Denmark, the Netherlands, USA and United Kingdom collected data on all patients triggering RRT review concerning the nature, trigger and immediate outcome of RRT review. Further follow-up at 24 h following RRT review focused on patient orientated outcomes including need for admission to critical care, change in limitations of therapy and all cause mortality. Results: We studied 1188 RRT activations. Derangement of vital signs as measured by the National Early Warning Score (NEWS) was more common in non-UK hospitals (p = 0.03). Twenty four hour mortality after RRT review was 10.1% (120/1188). Urgent transfer to ICU or the operating theatre occurred in 24% (284/1188) and 3% (40/1188) of events, respectively. Patients in the UK were less likely to be admitted to ICU (31% vs. 22%; p = 0.017) and their median (IQR) time to ICU admission was longer [4.4 (2.0-11.8) vs. 1.5 (0.8-4.4) h; p < 0.001]. RRT involvement lead to new limitations in care in 28% of the patients not transferring to the ICU; in the UK such limitations were instituted in 21% of patients while this occurred in 40% of non-UK patients (p < 0.001). Conclusion: Among patients triggering RRT review, 1 in 10 died within 24 h; 1 in 4 required ICU admission, and 1 in 4 had new limitations in therapy implemented. We provide a template for an international comparison of outcomes at RRT level.
Critical Care Medicine, 2013
Objective: The effectiveness of rapid response teams remains controversial. However, many studied rapid response teams were not intensivist-led, had limited involvement beyond the initial activations, and did not provide post-ICU follow-up. The objective of this study was to examine the impact of implementing an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality. Design: This was a pre-post rapid response team implementation study. Setting: Tertiary care academic center in Saudi Arabia. Patients: A total of 98,391 patients in the 2-yr pre-rapid response team and 157,804 patients in the 3-yr post-rapid response team implementation were evaluated. Intervention: The rapid response team was activated by any health care provider based on pre-defined criteria and a four-member intensivist-led multidisciplinary rapid response team responded to provide the necessary management and disposition. The rapid response team function was extended to provide follow-up until clinical stabilization. In addition, the rapid response team provided a mandatory post-ICU follow-up for a minimum of 48 hrs. Measurements and Main Results: The primary outcomes were cardiopulmonary arrests and mortality. After rapid response team implementation, non-ICU cardiopulmonary arrests decreased from 1.4 to 0.9 per 1,000 hospital admissions (relative risk, 0.68; 95% confidence interval, 0.53-0.86; p = 0.001) and total hospital mortality decreased from 22.5 to 20.2 per 1,000 hospital admissions (relative risk, 0.90; 95% confidence interval, 0.85-0.95; p < 0.0001). For patients who required admission to the ICU, there was a significant reduction in the Acute Physiology and Chronic Health Evaluation II scores after rapid response team implementation from 29.3 ± 9.3 to 26.9 ± 8.5 (p < 0.0001), with reduction in hospital mortality from 57.4% to 48.7% (relative risk, 0.85; 95% confidence interval, 0.78-0.92; p < 0.0001). Do-not-resuscitate orders for ward referrals increased from 0.7 to 1.7 per 1,000 hospital admissions (relative risk, 2.58; 95% confidence interval, 1.95-3.42; p < 0.0001) and decreased for patients admitted to ICU from the wards from 30.5% to 26.1% (relative risk, 0.86; 95% confidence interval, 0.74-0.99; p = 0.03). Additionally, ICU readmission rate decreased from 18.6 to 14.3 per 100 ICU alive discharges (relative risk, 0.77; 95% confidence interval, 0.66-0.89; p < 0.0001) and post-ICU hospital mortality from 18.2% to 14.8% (relative risk, 0.85; 95% confidence interval, 0.72-0.99; p = 0.04). Conclusion: The implementation of rapid response team was effective in reducing cardiopulmonary arrests and total hospital mortality for ward patients, improving the outcomes of patients who needed ICU admission and reduced readmissions and mortality of patients who were discharged from the ICU.
Canadian journal of anaesthesia = Journal canadien d'anesthesie, 2018
Rapid response systems (RRSs) have been introduced into hospitals to help reduce the incidence of sudden cardiopulmonary arrest (CPA). This study evaluated whether an RRS reduces the incidence of in-hospital postoperative CPA. This retrospective before-and-after analysis evaluated data collected from electronic medical records during a pre-intervention (January 2008 to September 2012) and post-intervention (implementation of an RRS) interval (October 2012 to December 2016) at a single tertiary care institution. The primary outcome was a change in the rate of CPA in surgical patients recovering in a general ward. A Poisson regression analysis adjusted for the Charlson Comorbidity Index (CCI) was used to compare CPA rates during these two intervals. Of the 207,054 surgical procedures performed during the study period, mean (95% confidence interval [CI]) CPA events per 10,000 cases of 7.46 (5.72 to 9.19) and 5.19 (3.85 to 6.52) were recorded before and after RRS intervention, respectiv...