A trial of a real‐time Alert for clinical deterioration in Patients hospitalized on general medical wards

Abstract

BACKGROUND With limited numbers of intensive care unit (ICU) beds available, increasing patient acuity is expected to contribute to episodes of inpatient deterioration on general wards. OBJECTIVE To prospectively validate a predictive algorithm for clinical deterioration in general–medical ward patients, and to conduct a trial of real‐time alerts based on this algorithm. DESIGN Randomized, controlled crossover study. SETTING/PATIENTS Academic center with patients hospitalized on 8 general wards between July 2007 and December 2011. INTERVENTIONS Real‐time alerts were generated by an algorithm designed to predict the need for ICU transfer using electronically available data. The alerts were sent by text page to the nurse manager on intervention wards. MEASUREMENTS Intensive care unit transfer, hospital mortality, and hospital length of stay. RESULTS Patients meeting the alert threshold were at nearly 5.3‐fold greater risk of ICU transfer (95% confidence interval [CI]: 4.6‐6.0) than those not satisfying the alert threshold (358 of 2353 [15.2%] vs 512 of 17678 [2.9%]). Patients with alerts were at 8.9‐fold greater risk of death (95% CI: 7.4‐10.7) than those without alerts (244 of 2353 [10.4%] vs 206 of 17678 [1.2%]). Among patients identified by the early warning system, there were no differences in the proportion of patients who were transferred to the ICU or who died in the intervention group as compared with the control group. CONCLUSIONS Real‐time alerts were highly specific for clinical deterioration resulting in ICU transfer and death, and were associated with longer hospital length of stay. However, an intervention notifying a nurse of the risk did not result in improvement in these outcomes. Journal of Hospital Medicine 2013;8:236–242. © 2013 Society of Hospital Medicine

Clinical performance of an interactive clinical decision support system for assessment of plasma lactate in hospitalized patients with organ dysfunction

“…Our simple treatment of vital sign abnormalities as markers of SIRS is not as elaborate as in many EWSs. Our study is only hypothesis-generating, whereas several EWSs are well validated (25,32). We cannot provide data on how our alert might change bedside interventions by clinicians.…”

“…One review of 39 EWSs reported PPVs ranging from 13.5-26.1% (34), and another review of 25 systems reported a median PPV of 36.7% with interquartile range 29.3-43.8% (34). PPV was not reported for several of the most elegant and well-studied EWSs (22,23,25,32). From the perspective of bedside clinicians and rapid response team members, the efficiency of an alert system is strongly influenced by the PPV, because a poor PPV translates to frequent false alerts.…”

“…These typically monitor for abnormal vital signs or laboratory evidence of organ dysfunction, but have included many other types of clinical and laboratory variables (20)(21)(22)(23). Modern EWSs utilize logistic regression to weight up to 36 different independent variables and yield highly stratified risk scores (24)(25)(26).…”

Early Warning Score Communication Bundle: A Pilot Study

“…The lack of communication and action may explain the conflicting findings reported by Smith and others. 7 To improve communication, Bailey and colleagues 8 added an EWS alert to the medical-surgical charge nurse's pager but could not explain a lack of improvement in patients' outcomes, suggesting that a more integrated approach to identify interventions is needed. Jackson and others 9 reported a strong negative correlation between medical-surgical nurses' years of experience and reluctance to activate an RRT call.…”

Factors Influencing Registered Nurses’ Decision to Activate an Adult Rapid Response Team in a Community Hospital

“…In an effort to improve identification of objective criteria indicating clinical deterioration, objective data, real-time alerts to nursing staff, and automated monitors have been implemented with conflicting impact on outcome measures. 15,[20][21][22][23] The activation of the RRT is likely based not only on objective information but also on the nurse forming a clinical judgment about the situation and seeking assistance within the context of their organizational cultures.…”