scholarly journals Increased time from physiological derangement to critical care admission associates with mortality

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Stephen F. Whebell ◽  
Emma J. Prower ◽  
Joe Zhang ◽  
Megan Pontin ◽  
David Grant ◽  
...  
Keyword(s):  
Critical Care ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Patient Outcomes ◽  
Patient Factors ◽  
Out Of Hours ◽  
Rapid Response Systems ◽  
Co Morbidity ◽  
Critical Care Admission ◽  
Response Systems

Abstract Background Rapid response systems aim to achieve a timely response to the deteriorating patient; however, the existing literature varies on whether timing of escalation directly affects patient outcomes. Prior studies have been limited to using ‘decision to admit’ to critical care, or arrival in the emergency department as ‘time zero’, rather than the onset of physiological deterioration. The aim of this study is to establish if duration of abnormal physiology prior to critical care admission [‘Score to Door’ (STD) time] impacts on patient outcomes. Methods A retrospective cross-sectional analysis of data from pooled electronic medical records from a multi-site academic hospital was performed. All unplanned adult admissions to critical care from the ward with persistent physiological derangement [defined as sustained high National Early Warning Score (NEWS) > / = 7 that did not decrease below 5] were eligible for inclusion. The primary outcome was critical care mortality. Secondary outcomes were length of critical care admission and hospital mortality. The impact of STD time was adjusted for patient factors (demographics, sickness severity, frailty, and co-morbidity) and logistic factors (timing of high NEWS, and out of hours status) utilising logistic and linear regression models. Results Six hundred and thirty-two patients were included over the 4-year study period, 16.3% died in critical care. STD time demonstrated a small but significant association with critical care mortality [adjusted odds ratio of 1.02 (95% CI 1.0–1.04, p = 0.01)]. It was also associated with hospital mortality (adjusted OR 1.02, 95% CI 1.0–1.04, p = 0.026), and critical care length of stay. Each hour from onset of physiological derangement increased critical care length of stay by 1.2%. STD time was influenced by the initial NEWS, but not by logistic factors such as out-of-hours status, or pre-existing patient factors such as co-morbidity or frailty. Conclusion In a strictly defined population of high NEWS patients, the time from onset of sustained physiological derangement to critical care admission was associated with increased critical care and hospital mortality. If corroborated in further studies, this cohort definition could be utilised alongside the ‘Score to Door’ concept as a clinical indicator within rapid response systems.

scholarly journals Reduced critical care demand with early CPAP and proning in COVID-19 at Bradford: A single-centre cohort

2021 ◽  
pp. 175114372110186
Author(s):  
Tom Lawton ◽  
Kate Wilkinson ◽  
Aaron Corp ◽  
Rabeia Javid ◽  
Laura MacNally ◽  
...  
Keyword(s):  
Critical Care ◽  
Hospital Mortality ◽  
Outreach Program ◽  
High Clinical Suspicion ◽  
Early Intubation ◽  
Co Morbidity ◽  
Critical Care Admission ◽  
Poor Outcomes ◽  
Care Capacity ◽  
Program Data

Background Guidance in COVID-19 respiratory failure has favoured early intubation, with concerns over the use of CPAP. We adopted early CPAP and self-proning, and evaluated the safety and efficacy of this approach. Methods This retrospective observational study included all patients with a positive COVID-19 PCR, and others with high clinical suspicion. Our protocol advised early CPAP and self-proning for severe cases, aiming to prevent rather than respond to deterioration. CPAP was provided outside critical care by ward staff supported by physiotherapists and an intensive critical care outreach program. Data were analysed descriptively and compared against a large UK cohort (ISARIC). Results 559 patients admitted before 1 May 2020 were included. 376 were discharged alive, and 183 died. 165 patients (29.5%) received CPAP, 40 (7.2%) were admitted to critical care and 28 (5.0%) were ventilated. Hospital mortality was 32.7%, and 50% for critical care. Following CPAP, 62% of patients with S:F or P:F ratios indicating moderate or severe ARDS, who were candidates for escalation, avoided intubation. Figures for critical care admission, intubation and hospital mortality are lower than ISARIC, whilst critical care mortality is similar. Following ISARIC proportions we would have admitted 92 patients to critical care and intubated 55. Using the described protocol, we intubated 28 patients from 40 admissions, and remained within our expanded critical care capacity. Conclusion Bradford’s protocol produced good results despite our population having high levels of co-morbidity and ethnicities associated with poor outcomes. In particular we avoided overloading critical care capacity. We advocate this approach as both effective and safe.

scholarly journals Effect of rapid response systems on hospital mortality: a systematic review and meta-analysis

2016 ◽  
Vol 42 (4) ◽  
pp. 615-617 ◽  
Author(s):  
Audrey De Jong ◽  
Boris Jung ◽  
Aurelien Daurat ◽  
Gerald Chanques ◽  
Martin Mahul ◽  
...  
Keyword(s):  
Systematic Review ◽  
Hospital Mortality ◽  
Meta Analysis ◽  
Rapid Response ◽  
Rapid Response Systems ◽  
Response Systems

scholarly journals EP.WE.573Outcomes of Emergency Laparotomies during the COVID-19 Pandemic - A retrospective cohort study

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Nader Habib Bedwani ◽  
William English ◽  
Christopher Smith ◽  
Shailendra Singh ◽  
Paul Vulliamy ◽  
...  
Keyword(s):  
Critical Care ◽  
Cohort Study ◽  
Respiratory Failure ◽  
Length Of Stay ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Emergency Laparotomy ◽  
Platelet Counts ◽  
Critical Care Admission ◽  
Grade 3

Abstract Aims A better understanding of patient monitoring and outcomes is required following emergency laparotomy. We aimed to evaluate recovery following emergency laparotomy during the ‘first wave’ of the COVID-19 pandemic and assess for COVID-19-associated coagulopathy in this group. Methods We performed a single-centre, retrospective cohort study on adult patients undergoing emergency laparotomy from 23rdMarch – 16thMay 2020 comparing patients with or without suspected or confirmed SARS-CoV-2. Main outcome measures included; 30-day mortality, post-operative respiratory failure, ARDS and other complications, critical care admission and length of stay (CCLOS) and total length of stay (LOS). Laboratory results were collected for three days post-operatively including platelet counts and clotting screen. Results 33 patients undergoing 36 emergency laparotomies were included, of which 9 had confirmed or suspected COVID-19. Patients with COVID-19 were more likely to have severe complications (Clavien-Dindo grade ≥3) (9/9 vs 5/24; p < 0.001), post-operative respiratory failure (9/9 vs 2/24; p < 0.001), ARDS (3/9 vs 0/24; p = 0.015) and need for critical care stay (9/9 vs 12/24; p = 0.012) with a longer LOS and CCLOS (17 vs 7 days; p = 0.004 and 6 vs 1 day; p < 0.001 respectively). Platelet counts were consistently lower on all peri-operative days and patients had a higher incidence of coagulopathy (7/11 vs 3/17; p = 0.020). Conclusions Emergency laparotomy is associated with increased post-operative morbidity in patients with confirmed or suspected COVID-19 with increased respiratory complications and critical care stay. Post-operative patients with COVID-19 show mildly reduced platelet counts and deranged clotting that may be part of a COVID-19-associated coagulopathy.

scholarly journals In-hospital emergencies versus out-of-hospital emergencies admitted to ICU: is the outcome different? An observational study

2021 ◽  
Author(s):  
Emi Cauchois ◽  
Jérémy Bourenne ◽  
Audrey Le Saux ◽  
Fouad Bouzana ◽  
Antoine Tilmont ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Hospital Mortality ◽  
Hospital Admissions ◽  
Rapid Response ◽  
University Hospital ◽  
Admission Diagnosis ◽  
Medical Systems ◽  
Rapid Response Systems ◽  
Response Systems

Abstract Background: Rapid Response Systems (RRS) are now commonly implemented throughout hospital health systems to manage in-hospital emergencies (IHE). There is limited data on characteristics and outcomes of such patients admitted to an intensive care unit (ICU). The goal was to determine whether the hospital mortality of ICU patients was different depending on their admission pathway: in-hospital via rapid response teams (RRT), or out-of-hospital emergencies (OHE) via prehospital emergency medical systems. Results: Out of 422 ICU admissions (Timone University Hospital ICU), 241 patients were retrospectively (2019-2020) included: 74 IHE versus 167 OHE. In-hospital mortality rates did not differ between both cohorts (n = 31(42%) vs. 63(39%) respectively, NS). IHE patients were older and had more comorbidities (immunosuppression and ongoing malignancy). OHE patients had more severe organ failures at presentation with more frequent mechanical ventilation support. Independent global hospital mortality risk factors were ongoing malignancy (OR = 10.4 [2.7-40], p < 0.001), SAPS II (OR = 1.05 [1.03-1.08], p < 0.0001) and SOFA scores (OR = 1.14 [1.01-1.3], p < 0.05), hemorrhagic stroke as admission diagnosis (OR = 8.4 [2.7-26], p < 0.001), and arterial lactate on arrival (OR = 1.11 [1.03-1.2], p < 0.01). Conclusion: This study provides a thorough and comprehensive analysis of characteristics and outcomes of ICU admissions following a mature rapid response activation system, compared to the “conventional” out-of-hospital admission pathway. Despite the more vulnerable background of IHE patients, hospital mortality does not differ, supporting the use of early RRS to identify deteriorating ward patients. Take-home message: Hospital mortality does not differ between in-hospital emergencies admitted to intensive care unit and conventional out-of-hospital admissions, supporting the use of early rapid response systems and the importance of early intensive care unit admission.

Overcoming Barriers Impeding Nurse Activation of Rapid Response Teams

2019 ◽  
Vol 24 (3) ◽  
Author(s):  
Wendy Clayton
Keyword(s):  
Patient Outcomes ◽  
Clinical Judgment ◽  
Rapid Response ◽  
Rapid Response Teams ◽  
Bedside Nurse ◽  
Patient Deterioration ◽  
Rapid Response Systems ◽  
Trained Personnel ◽  
Response Systems ◽  
Improve Patient

Management of rapid patient deterioration requires prompt recognition and swift response by bedside nurses and specially trained personnel, who successfully intervene to improve patient outcomes. Timely recognition and activation of rapid response mechanisms requires prudent nursing care. When patient needs and nurse competencies are unbalanced, patient outcomes decline and nurse confidence diminishes. This article offers a brief background of rapid response, including the supporting theoretical framework. Also discussed are barriers to nursing action that result in synergistic imbalance, including: bedside nurse competence to recognize patient deterioration and activate rapid response systems; bedside nurse clinical judgment, interdisciplinary teamwork; and organizational culture. The article includes implications for practice aims to address identified barriers and improve patient outcomes.

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