IntroductionRapid response teams (RRTs) have been shown to reduce cardiopulmonary arrests outside the intensive care unit (ICU). Yet the utility of RRTs remains in question, as most large studies have failed to demonstrate a significant reduction in hospital-wide mortality after RRT implementation.MethodsA cohort design with historical controls was used to determine the effect on hospital-wide mortality of an RRT in which clinical judgment, in addition to vital-signs criteria, was widely promoted as a key trigger for activation. All nonprisoner patients admitted to a tertiary referral public teaching hospital from 2003 through 2008 were included. In total, 77, 021 admissions before RRT implementation (2003 through 2005) and 79, 013 admissions after RRT implementation (2006 through 2008) were evaluated. The a priori primary outcome was unadjusted hospital-wide mortality. A Poisson regression model was then used to adjust for hospital-wide mortality trends over time. Secondary outcomes defined a priori were unadjusted out-of-ICU mortality and out-of-ICU cardiopulmonary-arrest codes.ResultsIn total, 855 inpatient RRTs (10.8 per 1, 000 hospital-wide discharges) were activated during the 3-year postintervention period. Forty-seven percent of RRTs were activated for reasons of clinical judgment. Hospital-wide mortality decreased from 15.50 to 13.74 deaths per 1, 000 discharges after RRT implementation (relative risk, 0.887; 95% confidence interval (CI), 0.817 to 0.963; P = 0.004). After adjusting for inpatient mortality trends over time, the reduction in hospital-wide mortality remained statistically significant (relative risk, 0.825; 95% CI, 0.694 to 0.981; P = 0.029). Out-of-ICU mortality decreased from 7.08 to 4.61 deaths per 1, 000 discharges (relative risk, 0.651; 95% CI, 0.570 to 0.743; P < 0.001). Out-of-ICU cardiopulmonary-arrest codes decreased from 3.28 to 1.62 codes per 1, 000 discharges (relative risk, 0.493; 95% CI, 0.399 to 0.610; P < 0.001).ConclusionsImplementation of an RRT in which clinical judgment, in addition to vital-signs criteria, was widely cited as a rationale for activation, was associated with a significant reduction in hospital-wide mortality, out-of-ICU mortality, and out-of-ICU cardiopulmonary-arrest codes. The frequent use of clinical judgment as a criterion for RRT activation was associated with high RRT utilization.

BACKGROUND Understanding the mechanism of unplanned hospital readmissions is necessary for accurate prediction and prevention. OBJECTIVE To identify specific mechanisms of unplanned readmissions through medical narratives obtained from chart reviews. DESIGN Retrospective chart review. SETTING Urban tertiary care hospital. PATIENTS Two hundred seventy patients accounted for 335 unplanned 7‐day readmissions between July 2010 and July 2011. MEASUREMENTS Readmissions were classified into 1 of 5 distinct categories. RESULTS Readmitted subjects were more likely to have had a longer length of stay during the first admission compared to nonreadmitted patients. Readmissions due to unpredictable/unpreventable complications or unrelated events constituted the highest percentage at 46%. Readmissions due to patient factors such as substance abuse, signing out against medical advice, or nonadherence to the treatment plan constituted 31%. Readmissions designated as preventable accounted for 24%. Among preventable readmissions, the most common cause was incomplete management of the index diagnosis. The interobserver level of agreement across the 5 major categories was substantial. CONCLUSIONS We found through detailed chart review of patients readmitted within 7 days to an urban teaching hospital that the majority of readmissions were not avoidable and were often due to unpredictable or unpreventable complications of the primary diagnosis from the index hospitalization or to patient behaviors that contradicted the treatment plan. These results question the value of readmissions as a valid metric of quality and support future interventions in hospital systems to reduce preventable readmissions. Journal of Hospital Medicine 2016;11:33–38. © 2015 Society of Hospital Medicine

Coronary artery disease (CAD) is the leading cause of death in Americans, accounting for about 500,000 deaths every year. The annual incidence of myocardial infarction (MI) is about 1.5 million. As many as 2 million middle-aged men may have silent myocardial ischemia. (1)

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EPIDEMIOLOGY• For all persons aged 20 years and older, the prevalence of cholesterol levels of Ն6.21 mmol/L (Ն240 mg/dL) was 18%• Women have a marked increase in rates of hypercholesterolemia after menopause Factors that influence lipid values• Acute myocardial infarction (MI): transient decrease in LDL-C and total cholesterol levels (nadir 1-2 weeks after MI). Triglyceride levels peak 3 weeks after MI. Values return to baseline in about 6 weeks