Performance of the Afferent Limb of Rapid Response Systems in Managing Deteriorating Patients: A Systematic Review

Introduction. The clinical components of the rapid response system (RRS) are the afferent limb, to ensure identification of in-hospital patients who deteriorate and activation of a response, and the efferent limb, to provide the response. This review aims to evaluate the factors that influence the performance of the afferent limb in managing deteriorating ward patients and their effects on patient outcomes. Methods. A systematic review was performed for the years 1995–2017 by employing five electronic databases. Articles were included assessing the ability of the ward staffs to monitor, recognize, and escalate care to patient deterioration. The findings were summarized using a narrative approach. Results. Thirty-one studies met the inclusion criteria. The analysis revealed major themes enclosing several factors affecting management of patients having sudden deterioration. The monitoring and recognition process was conditioned by the lack of recording of physiological parameters, the influence of facilitators, including staff education and training, and barriers, including human and environmental factors, and poor compliance with the calling criteria. The escalation of care process highlighted the influence of cultural barriers and personal judgment on RRS activation. Mainly, delayed team calls were factors strongly associated with the increased risk of unplanned admissions to the intensive care unit and length of stay, hospital length of stay and mortality, and 30-day mortality. Conclusions. A combination of factors affects the timely identification and response to sudden deterioration by general ward staffs, leading to suboptimal care of patients, delayed or failed activation of RRS teams, and increased risks of worsening outcomes. The research efforts and clinical involvement to improve the governance of the factors limiting the performance of the afferent limb may ensure proper management of hospitalized patients showing physiological deterioration.

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The effectiveness of in-hospital interventions on reducing hospital length of stay and readmission of patients with Type 2 Diabetes Mellitus: a systematic review

Diabetes Research and Clinical Practice ◽

10.1016/j.diabres.2020.108363 ◽

2020 ◽

pp. 108363

Author(s):

Amal Chakraborty ◽

Odette Pearson ◽

Kate M. Schwartzkopff ◽

Iris O'rourke ◽

Isuru Ranasinghe ◽

...

Keyword(s):

Diabetes Mellitus ◽

Systematic Review ◽

Type 2 Diabetes ◽

Type 2 Diabetes Mellitus ◽

Length Of Stay ◽

Hospital Length ◽

Hospital Length Of Stay

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An Organizational-Level Program of Intervention for AKI: A Pragmatic Stepped Wedge Cluster Randomized Trial

Journal of the American Society of Nephrology ◽

10.1681/asn.2018090886 ◽

2019 ◽

Vol 30 (3) ◽

pp. 505-515 ◽

Cited By ~ 33

Author(s):

Nicholas M. Selby ◽

Anna Casula ◽

Laura Lamming ◽

John Stoves ◽

Yohan Samarasinghe ◽

...

Keyword(s):

Length Of Stay ◽

Randomized Trial ◽

Cluster Randomized Trial ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Organizational Level ◽

Care Process ◽

Standards Of Care ◽

Stepped Wedge ◽

Cluster Randomized

BackgroundVariable standards of care may contribute to poor outcomes associated with AKI. We evaluated whether a multifaceted intervention (AKI e-alerts, an AKI care bundle, and an education program) would improve delivery of care and patient outcomes at an organizational level.MethodsA multicenter, pragmatic, stepped-wedge cluster randomized trial was performed in five UK hospitals, involving patients with AKI aged ≥18 years. The intervention was introduced sequentially across fixed three-month periods according to a randomly determined schedule until all hospitals were exposed. The primary outcome was 30-day mortality, with pre-specified secondary endpoints and a nested evaluation of care process delivery. The nature of the intervention precluded blinding, but data collection and analysis were independent of project delivery teams.ResultsWe studied 24,059 AKI episodes, finding an overall 30-day mortality of 24.5%, with no difference between control and intervention periods. Hospital length of stay was reduced with the intervention (decreases of 0.7, 1.1, and 1.3 days at the 0.5, 0.6, and 0.7 quantiles, respectively). AKI incidence increased and was mirrored by an increase in the proportion of patients with a coded diagnosis of AKI. Our assessment of process measures in 1048 patients showed improvements in several metrics including AKI recognition, medication optimization, and fluid assessment.ConclusionsA complex, hospital-wide intervention to reduce harm associated with AKI did not reduce 30-day AKI mortality but did result in reductions in hospital length of stay, accompanied by improvements in in quality of care. An increase in AKI incidence likely reflected improved recognition.

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Impact of Frailty on Outcomes Following Spine Surgery: A Prospective Cohort Analysis of 668 Patients

Neurosurgery ◽

10.1093/neuros/nyaa468 ◽

2020 ◽

Author(s):

Nitin Agarwal ◽

Ezequiel Goldschmidt ◽

Tavis Taylor ◽

Souvik Roy ◽

Stefanie C Altieri Dunn ◽

...

Keyword(s):

Length Of Stay ◽

Spine Surgery ◽

Cohort Analysis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Quality Improvement Initiative ◽

Exact Test ◽

Frail Patients ◽

Increased Risk ◽

Venous Thromboembolic

Abstract BACKGROUND With an aging population, elderly patients with multiple comorbidities are more frequently undergoing spine surgery and may be at increased risk for complications. Objective measurement of frailty may predict the incidence of postoperative adverse events. OBJECTIVE To investigate the associations between preoperative frailty and postoperative spine surgery outcomes including mortality, length of stay, readmission, surgical site infection, and venous thromboembolic disease. METHODS As part of a system-wide quality improvement initiative, frailty assessment was added to the routine assessment of patients considering spine surgery beginning in July 2016. Frailty was assessed with the Risk Analysis Index (RAI), and patients were categorized as nonfrail (RAI 0-29) or prefrail/frail (RAI ≥ 30). Comparisons between nonfrail and prefrail/frail patients were analyzed using Fisher's exact test for categorical data or by Wilcoxon rank sum tests for continuous data. RESULTS From August 2016 through September 2018, 668 patients (age of 59.5 ± 13.3 yr) had a preoperative RAI score recorded and underwent scheduled spine surgery. Prefrail and frail patients suffered comparatively higher rates of mortality at 90 d (1.9% vs 0.2%, P < .05) and 1 yr (5.1% vs 1.2%, P < .01) from the procedure date. They also had longer in-hospital length of stay (LOS) (3.9 d ± 3.6 vs 3.1 d ± 2.8, P < .001) and higher rates of 60 d (14.6% vs 8.2%, P < .05) and 90 d (15.8% vs 9.8%, P < .05) readmissions. CONCLUSION Preoperative frailty, as measured by the RAI, was associated with an increased risk of readmission and 90-d and 1-yr mortality following spine surgery. The RAI can be used to stratify spine patients and inform preoperative surgical decision making.

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Use of a Clustered Model to Identify Factors Affecting Hospital Length of Stay

Journal of Clinical Epidemiology ◽

10.1016/s0895-4356(99)00079-7 ◽

1999 ◽

Vol 52 (11) ◽

pp. 1031-1036 ◽

Cited By ~ 13

Author(s):

Yael C Cohen ◽

Haya R Rubin ◽

Laurence Freedman ◽

Benjamin Mozes

Keyword(s):

Length Of Stay ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Factors Affecting

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Childhood Nephrotic Syndrome Management and Outcome: A Single Center Retrospective Analysis

International Journal of Nephrology ◽

10.1155/2017/2029583 ◽

2017 ◽

Vol 2017 ◽

pp. 1-7 ◽

Cited By ~ 7

Author(s):

Chia-shi Wang ◽

Jia Yan ◽

Robert Palmer ◽

James Bost ◽

Mattie Feasel Wolf ◽

...

Keyword(s):

Nephrotic Syndrome ◽

Length Of Stay ◽

Hospital Length ◽

Hospital Length Of Stay ◽

High Morbidity ◽

Metropolitan Statistical Area ◽

Childhood Nephrotic Syndrome ◽

Steroid Dependent ◽

Increased Risk ◽

Serious Disease

There is a paucity of information on outpatient management and risk factors for hospitalization and complications in childhood nephrotic syndrome (NS). We described the management, patient adherence, and inpatient and outpatient usage of 87 pediatric NS patients diagnosed between 2006 and 2012 in the Atlanta Metropolitan Statistical Area. Multivariable analyses were performed to examine the associations between patient characteristics and disease outcome. We found that 51% of the patients were treated with two or more immunosuppressants. Approximately half of the patients were noted to be nonadherent to medications and urine protein monitoring. The majority (71%) of patients were hospitalized at least once, with a median rate of 0.5 hospitalizations per patient year. Mean hospital length of stay was 4.0 (3.8) days. Fourteen percent of patients experienced at least one serious disease complication. Black race, frequently relapsing/steroid-dependent and steroid-resistant disease, and the first year following diagnosis were associated with higher hospitalization rates. The presence of comorbidities was associated with longer hospital length of stay and increased risk of serious disease complications. Our results highlight the high morbidity and burden of NS and point to particular patient subgroups that may be at increased risk for poor outcome.

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Optimal use of tocilizumab for severe and critical COVID-19: a systematic review and meta-analysis

F1000Research ◽

10.12688/f1000research.45046.1 ◽

2021 ◽

Vol 10 ◽

pp. 73

Author(s):

Cahyo Wibisono Nugroho ◽

Satriyo Dwi Suryantoro ◽

Yuliasih Yuliasih ◽

Alfian Nur Rosyid ◽

Tri Pudy Asmarawati ◽

...

Keyword(s):

Systematic Review ◽

Length Of Stay ◽

Critically Ill ◽

Meta Analysis ◽

Standard Of Care ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Eligibility Criteria ◽

All Cause Mortality ◽

Clinical Benefits

Background: Several studies have revealed the potential use of tocilizumab in treating COVID-19 since no therapy has yet been approved for COVID-19 pneumonia. Tocilizumab may provide clinical benefits for cytokine release syndrome in COVID-19 patients. Methods: We searched for relevant studies in PubMed, Embase, Medline, and Cochrane published from March to October 2020 to evaluate optimal use and baseline criteria for administration of tocilizumab in severe and critically ill COVID-19 patients. Research involving patients with confirmed SARS-CoV-2 infection, treated with tocilizumab and compared with the standard of care (SOC) was included in this study. We conducted a systematic review to find data about the risks and benefits of tocilizumab and outcomes from different baseline criteria for administration of tocilizumab as a treatment for severe and critically ill COVID-19 patients. Results: A total of 26 studies, consisting of 23 retrospective studies, one prospective study, and two randomised controlled trials with 2112 patients enrolled in the tocilizumab group and 6160 patients in the SOC group, were included in this meta-analysis. Compared to the SOC, tocilizumab showed benefits for all-cause mortality events and a shorter time until death after first intervention but showed no difference in hospital length of stay. Upon subgroup analysis, tocilizumab showed fewer all-cause mortality events when CRP level ≥100 mg/L, P/F ratio 200-300 mmHg, and P/F ratio <200 mmHg. However, tocilizumab showed a longer length of stay when CRP <100 mg/L than the SOC. Conclusion: This meta-analysis demonstrated that tocilizumab has a positive effect on all-cause mortality. It should be cautiously administrated for optimal results and tailored to the patient's eligibility criteria.

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Laparoscopic Shunt Revision Avoids Many Complications of Open Shunt Revision and Has Outcomes Similar to First-time Shunt Placement

The American Surgeon ◽

10.1177/000313481508100335 ◽

2015 ◽

Vol 81 (3) ◽

pp. 305-308

Author(s):

Heather Logghe ◽

John Maa ◽

Michael McDermott ◽

Michael Oh ◽

Jonathan Carter

Keyword(s):

Length Of Stay ◽

Retrospective Cohort ◽

Operative Time ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Shunt Revision ◽

Visceral Injury ◽

Shunt Placement ◽

Increased Risk ◽

First Time

Open revision of abdominal shunts is associated with increased risk of wound infection, visceral injury, hernia, and shunt complications. We hypothesized that laparoscopic revision mitigates these risks to a level similar to initial (i.e., first-time) shunt placement. This was a single-center, multisurgeon, retrospective cohort study of patients who underwent either laparoscopic initial shunt placement or laparoscopic shunt revision over a 5-year period. Outcomes were operative time, length of stay, and 30-day complication rate. Sixty-nine patients underwent laparoscopic shunt revision and 99 patients underwent laparoscopic initial shunt placement. Operative times were nearly identical (75 vs 73 minutes, P = 0.63). There were no significant differences in blood loss or hospital length of stay. Abdominal complications and total complications did not differ between groups. Laparoscopic shunt revision avoided many of the known complications of open shunt revision and had outcomes similar to initial laparoscopic shunt placement.

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Routine Nasogastric Decompression in Small Bowel Obstruction: Is it Really Necessary?

The American Surgeon ◽

10.1177/000313481307900433 ◽

2013 ◽

Vol 79 (4) ◽

pp. 422-428 ◽

Cited By ~ 9

Author(s):

Annabelle L. Fonseca ◽

Kevin M. Schuster ◽

Adrian A. Maung ◽

Lewis J. Kaplan ◽

Kimberly A. Davis

Keyword(s):

Respiratory Failure ◽

Small Bowel ◽

Length Of Stay ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Retrospective Chart Review ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Increased Risk ◽

Nasogastric Decompression

Bowel rest, nasogastric (NG) decompression, and intravenous hydration are used to treat small bowel obstruction (SBO) conservatively; however, there are no data to support nasogastric tube (NGT) use in patients without active emesis. We aim to evaluate the use of nasogastric decompression in SBO and the safety of managing patients with SBO without the use of a NGT. A retrospective chart review was conducted of adult patients admitted to Yale New Haven Hospital over five years with the diagnosis of SBO. We compared patients who received NG decompression with those who did not. Outcome variables assessed were days to resolution, associated complications, hospital length of stay, and disposition. Of 290 patients who fit the criteria, 190 patients (65.52%) were managed conservatively. Fifty-five patients (18.97%) did not receive NGTs. Sixty-eight patients (23.45%) did not present with emesis; however, nearly 75 per cent of these patients received NGTs. Development of pneumonia and respiratory failure was significantly associated with NGT placement. Time to resolution and hospital length of stay were significantly higher in patients with NGTs. Patients with NG decompression had a significantly increased risk of pneumonia and respiratory failure as well as increased time to resolution and hospital length of stay.

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Clinical and Economic Outcomes of Telemedicine Programs in the Intensive Care Unit: A Systematic Review and Meta-Analysis

Journal of Intensive Care Medicine ◽

10.1177/0885066617726942 ◽

2017 ◽

Vol 33 (7) ◽

pp. 383-393 ◽

Cited By ~ 33

Author(s):

Jing Chen ◽

Dalong Sun ◽

Weiming Yang ◽

Mingli Liu ◽

Shufan Zhang ◽

...

Keyword(s):

Systematic Review ◽

Intensive Care Unit ◽

Intensive Care ◽

Length Of Stay ◽

Hospital Mortality ◽

Meta Analysis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Icu Length Of Stay ◽

The Impact

Objective: To evaluate the impact of telemedicine programs in intensive care unit (Tele-ICU) on ICU or hospital mortality or ICU or hospital length of stay and to summarize available data on implementation cost of Tele-ICU. Methods: Controlled trails or observational studies assessing outcomes of interest were identified by searching 7 electronic databases from inception to July 2016 and related journals and conference literatures between 2000 and 2016. Two reviewers independently screened searched records, extracted data, and assessed the quality of included studies. Random-effect models were applied to meta-analyses and sensitivity analysis. Results: Nineteen of 1035 records fulfilled the inclusion criteria. The pooled effects demonstrated that Tele-ICU programs were associated with reductions in ICU mortality (15 studies; risk ratio [RR], 0.83; 95% confidence interval [CI], 0.72 to 0.96; P = .01), hospital mortality (13 studies; RR, 0.74; 95% CIs, 0.58 to 0.96; P = .02), and ICU length of stay (9 studies; mean difference [MD], −0.63; 95% CI, −0.28 to 0.17; P = .007). However, there is no significant association between the reduction in hospital length of stay and Tele-ICU programs. Summary data concerning costs suggested approximately US$50 000 to US$100 000 per Tele-ICU bed was required to implement Tele-ICU programs for the first year. Hospital costs of US$2600 reduction to US$5600 increase per patient were estimated using Tele-ICU programs. Conclusions: This systematic review and meta-analysis provided limited evidence that Tele-ICU approaches may reduce the ICU and hospital mortality, shorten the ICU length of stay, but have no significant effect in hospital length of stay. Implementation of Tele-ICU programs substantially costs and its long-term cost-effectiveness is still unclear.

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