IntroductionRapid-response teams (RRTs) are interdisciplinary groups created to rapidly assess and treat patients with unexpected clinical deterioration marked by decline in vital signs. Traditionally emergency department (ED) disposition is partially based on the patients’ vital signs (VS) at the time of hospital admission. We aimed to identify which patients will have RRT activation within 12 hours of admission based on their ED VS, and if their outcomes differed.MethodsWe conducted a case-control study of patients presenting from January 2009 to December 2012 to a tertiary ED who subsequently had RRT activations within 12 hours of admission (early RRT activations). The medical records of patients 18 years and older admitted to a non-intensive care unit (ICU) setting were reviewed to obtain VS at the time of ED arrival and departure, age, gender and diagnoses. Controls were matched 1:1 on age, gender, and diagnosis. We evaluated VS using cut points (lowest 10%, middle 80% and highest 10%) based on the distribution of VS for all patients. Our study adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for reporting observational studies.ResultsA total of 948 patients were included (474 cases and 474 controls). Patients who had RRT activations were more likely to be tachycardic (odds ratio [OR] 2.02, 95% CI [1.25–3.27]), tachypneic (OR 2.92, 95% CI [1.73–4.92]), and had lower oxygen saturations (OR 2.25, 95% CI [1.42–3.56]) upon arrival to the ED. Patients who had RRT activations were more likely to be tachycardic at the time of disposition from the ED (OR 2.76, 95% CI [1.65–4.60]), more likely to have extremes of systolic blood pressure (BP) (OR 1.72, 95% CI [1.08–2.72] for low BP and OR 1.82, 95% CI [1.19–2.80] for high BP), higher respiratory rate (OR 4.15, 95% CI [2.44–7.07]) and lower oxygen saturation (OR 2.29, 95% CI [1.43–3.67]). Early RRT activation was associated with increased healthcare utilization and worse outcomes including increased rates of ICU admission within 72 hours (OR 38.49, 95%CI [19.03–77.87]), invasive interventions (OR 5.49, 95%CI [3.82–7.89]), mortality at 72 hours (OR 4.24, 95%CI [1.60–11.24]), and mortality at one month (OR 4.02, 95%CI [2.44–6.62]).ConclusionAfter matching for age, gender and ED diagnosis, we found that patients with an abnormal heart rate, respiratory rate or oxygen saturation at the time of ED arrival or departure are more likely to trigger RRT activation within 12 hours of admission. Early RRT activation was associated with higher mortality at 72 hours and one month, increased rates of invasive intervention and ICU admission. Determining risk factors of early RRT activation is of clinical, operational, and financial importance, as improved medical decision-making regarding disposition would maximize allocation of resources while potentially limiting morbidity and mortality.

IntroductionCurrent cognitive sciences describe decision-making using the dual-process theory, where a System 1 is intuitive and a System 2 decision is hypothetico-deductive. We aim to compare the performance of these systems in determining patient acuity, disposition and diagnosis.MethodsProspective observational study of emergency physicians assessing patients in the emergency department of an academic center. Physicians were provided the patient’s chief complaint and vital signs and allowed to observe the patient briefly. They were then asked to predict acuity, final disposition (home, intensive care unit (ICU), non-ICU bed) and diagnosis. A patient was classified as sick by the investigators using previously published objective criteria.ResultsWe obtained 662 observations from 289 patients. For acuity, the observers had a sensitivity of 73.9% (95% CI [67.7–79.5%]), specificity 83.3% (95% CI [79.5–86.7%]), positive predictive value 70.3% (95% CI [64.1–75.9%]) and negative predictive value 85.7% (95% CI [82.0–88.9%]). For final disposition, the observers made a correct prediction in 80.8% (95% CI [76.1–85.0%]) of the cases. For ICU admission, emergency physicians had a sensitivity of 33.9% (95% CI [22.1–47.4%]) and a specificity of 96.9% (95% CI [94.0–98.7%]). The correct diagnosis was made 54% of the time with the limited data available.ConclusionSystem 1 decision-making based on limited information had a sensitivity close to 80% for acuity and disposition prediction, but the performance was lower for predicting ICU admission and diagnosis. System 1 decision-making appears insufficient for final decisions in these domains but likely provides a cognitive framework for System 2 decision-making.

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Adolescents are at high-risk for sexually transmitted infections and pregnancy, yet many do not receive regular preventive care. Hospitalization represents an opportunity for providing sexual and contraception counseling for this high-risk population. Our aim in this study was to assess the frequency of sexual and contraception history documentation in hospitalized adolescents and identify subgroups that may benefit from more vigilant screening. METHODS:A retrospective chart review of adolescent patients 11 years of age and older who were discharged from the pediatric hospitalist service at an urban, academic children's hospital from July 2017 to June 2018 was conducted. Patient and admission characteristics were analyzed for presence of sexual and contraception history documentation. Technology-dependent patients were analyzed separately. In addition, technology-dependent patients were assessed by chart review for developmental appropriateness for screening.RESULTS: Twenty-five percent of patients (41 of 165) had a sexual history documented, and 8.5% (14 of 165) had a contraception history documented. Among patients with any technology dependence, 0 had a sexual history documented and only 1 had a contraception history documented, whereas 31.5% (12 of 38) were deemed developmentally appropriate for screening. Female and older patients were more likely to have sexual and contraceptive histories documented than male and younger patients. Patients transferred from the PICU had lower rates of sexual history documentation compared with direct admissions. CONCLUSIONS: Hospitalized adolescents, especially those with technology dependence, did not have adequate sexual and contraception histories documented. Improving documentation of these discussions is an important step in providing adolescents with preventive medicine services while hospitalized.

Introduction: Adolescents seek routine healthcare, including immunizations, less frequently than any other age group. Hospitalizations are an opportunity to provide immunizations to this vulnerable population. The aims of this study were to assess the accuracy of provider documentation of immunization status and evaluate the prevalence of delayed immunization status in this population. Methods: A retrospective chart review of adolescents discharged from July 2017 to June 2018 from the pediatric hospitalist service of a tertiary care academic childrens hospital was conducted. Provider documentation of immunization status was compared to the immunization registry ALERT Immunization Information System (ALERT IIS) linked to the electronic medical record using descriptive statistics. Results: Provider documentation of up-to-date on all immunizations had a sensitivity of 60% and specificity of 55%, with 84% of patients needing at least one immunization despite 48% of patients being documented as up-to-date by providers. Provider documentation of the immunization status for the HPV, MCV and Tdap immunizations displayed a low sensitivity (10-11%) but a high specificity (97-100%) while documentation of the influenza immunization was associated with high sensitivity (86%) and low specificity (26%). Provider documentation of immunization status for the HPV, MCV, Tdap and influenza immunizations had positive likelihood ratios of 3.5, 8.5, infinity, and 1.2 with negative likelihood ratios of 0.9, 0.9, 0.9 and 0.53, respectively. Conclusions: Providers inaccurately documented the immunization status for adolescent patients in the inpatient setting. Hospitalizations may provide opportunities to improve immunization rates in adolescents, especially when using state immunization registries.

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