Background Clinically significant deterioration of patients admitted to general wards is a recognized complication of hospital care. Rapid Response Systems (RRS) aim to reduce the number of avoidable adverse events. The authors aimed to develop a core quality metric for the evaluation of RRS. Methods We conducted an international consensus process. Participants included patients, carers, clinicians, research scientists, and members of the International Society for Rapid Response Systems with representatives from Europe, Australia, Africa, Asia and the US. Scoping reviews of the literature identified potential metrics. We used a modified Delphi methodology to arrive at a list of candidate indicators that were reviewed for feasibility and applicability across a broad range of healthcare systems including low and middle-income countries. The writing group refined recommendations and further characterized measurement tools. Results Consensus emerged that core outcomes for reporting for quality improvement should include ten metrics related to structure, process and outcome for RRS with outcomes following the domains of the quadruple aim. The conference recommended that hospitals should collect data on cardiac arrests and their potential preventability, timeliness of escalation, critical care interventions and presence of written treatment plans for patients remaining on general wards. Unit level reporting should include the presence of patient activated rapid response and metrics of organizational culture. We suggest two exploratory cost metrics to underpin urgently needed research in this area. Conclusion A consensus process was used to develop ten metrics for better understanding the course and care of deteriorating ward patients. Others are proposed for further development. Results Consensus was achieved for ten RRS quality metrics, of which four were related to improving population health, three to enhancing the patient experience of care, two to cost and one to enhancing provider well-being. Level of recommendations were graded as "essential," "recommended", "optional" and "experimental". Terms used in the formulation of recommendations are described in Table 1. Table 2 provides a summary of specific numerators, denominators and inclusion and exclusion criteria to be used when tracking each entity. We are aware that many hospitals use a multi level activation system; for these institutions, we provide guidance in Table 2 as to which warning level should be used for a given metric. Recommendation 1: Hospitals should measure and track cardiac arrests of regular ward patients Type of metric: Clinical outcome, essential Description of metric: A cardiac arrest is defined as an event in which a patient receives chest compression and/or defibrillation for a non-perfusing rhythm. The definitions of terms used in this and other metrics are presented in Table 1. Rationale: Retrospective reviews of in-hospital cardiac arrests (IHCA) consistently show that signs of deterioration are present for several hours before the even...
IntroductionRapid Response Systems were created to minimise delays in recognition and treatment of deteriorating patients on general wards. Physiological 'track and trigger' systems are used to alert a team with critical care skills to stabilise patients and expedite admission to intensive care units. No benchmarking tool exists to facilitate comparison for quality assurance. This study was designed to create and test a tool to analyse the efficiency of intensive care admission processes.MethodsWe conducted a pilot multicentre service evaluation of patients admitted to 17 intensive care units from the United Kingdom, Ireland, Denmark, United States of America and Australia. Physiological abnormalities were recorded via a standardised track and trigger score (VitalPAC™ Early Warning Score). The period between the time of initial physiological abnormality (Score) and admission to intensive care (Door) was recorded as 'Score to Door Time'. Participants subsequently suggested causes for admission delays.ResultsScore to Door Time for 177 admissions was a median of 4:10 hours (interquartile range (IQR) 1:49 to 9:10). Time from physiological trigger to activation of a Rapid Response System was a median 0:47 hours (IQR 0:00 to 2:15). Time from call-out to intensive care admission was a median of 2:45 hours (IQR 1:19 to 6:32). A total of 127 (71%) admissions were deemed to have been delayed. Stepwise linear regression analysis yielded three significant predictors of longer Score to Door Time: being treated in a British centre, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score and increasing age. Binary regression analysis demonstrated a significant association (P < 0.045) of APACHE II scores >20 with Score to Door Times greater than the median 4:10 hours.ConclusionsScore to Door Time seemed to be largely independent of illness severity and, when combined with qualitative feedback from centres, suggests that admission delays could be due to organisational issues, rather than patient factors. Score to Door Time could act as a suitable benchmarking tool for Rapid Response Systems and helps to delineate avoidable organisational delays in the care of patients at risk of catastrophic deterioration.
Background‘Failure to rescue’ of hospitalized patients with deteriorating physiology on general wards is caused by a complex array of organisational, technical and cultural failures including a lack of standardized team and individual expected responses and actions. The aim of this study using a learning collaborative method was to develop consensus recomendations on the utility and effectiveness of checklists as training and operational tools to assist in improving the skills of general ward staff on the effective rescue of patients with abnormal physiology.MethodsA scoping study of the literature was followed by a multi-institutional and multi-disciplinary international learning collaborative. We sought to achieve a consensus on procedures and clinical simulation technology to determine the requirements, develop and test a safe using a checklist template that is rapidly accessible to assist in emergency management of common events for general ward use.ResultsSafety considerations about deteriorating patients were agreed upon and summarized. A consensus was achieved among an international group of experts on currently available checklist formats performing poorly in simulation testing as first responders in general ward clinical crises. The Crisis Checklist Collaborative ratified a consensus template for a general ward checklist that provides a list of issues for first responders to address (i.e. ‘Check In’), a list of prompts regarding common omissions (i.e. ‘Stop & Think’), and, a list of items required for the safe “handover” of patients that remain on the general ward (i.e. ‘Check Out’). Simulation usability assessment of the template demonstrated feasibility for clinical management of deteriorating patients.ConclusionsEmergency checklists custom-designed for general ward patients have the potential to guide the treatment speed and reliability of responses for emergency management of patients with abnormal physiology while minimizing the risk of adverse events. Interventional trials are needed.
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