Afferent limb failure revisited – A retrospective, international, multicentre, cohort study of delayed rapid response team calls

Tirkkonen, Joonas; Skrifvars, Markus B.; Tamminen, Tero; Parr, Michael; Hillman, Ken; Efendijev, Ilmar; Åneman, Anders

doi:10.1016/j.resuscitation.2020.08.117

Cited by 23 publications

(28 citation statements)

References 35 publications

(109 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Although we adjusted for potential confounders of the relationship between increasing time to RRT activation and mortality, our findings may have been impacted by residual confounding. It is possible, for example, that certain etiologies of deterioration—for example acute respiratory failure—are both more likely to result in increased time to RRT activation and higher RRT mortality ( 6 , 20 ). As such, these results should not be used as evidence that RRT deployment at a specific CART threshold will improve outcomes.…”

Section: Discussionmentioning

confidence: 99%

Association of Time to Rapid Response Team Activation With Patient Outcomes Using a Range of Physiologic Deterioration Thresholds

Mitchell

Neefe

Ginestra

et al. 2022

Critical Care Explorations

View full text Add to dashboard Cite

Clinical deterioration of hospitalized patients is common and can lead to critical illness and death. Rapid response teams (RRTs) assess and treat high-risk patients with signs of clinical deterioration to prevent further worsening and subsequent adverse outcomes. Whether activation of the RRT early in the course of clinical deterioration impacts outcomes, however, remains unclear. We sought to characterize the relationship between increasing time to RRT activation after physiologic deterioration and short-term patient outcomes. DESIGN:Retrospective multicenter cohort study. SETTING: Three academic hospitals in Pennsylvania. PATIENTS:We included the RRT activation of a hospitalization for non-ICU inpatients greater than or equal to 18 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:The primary exposure was time to RRT activation after physiologic deterioration. We selected four Cardiac Arrest Risk Triage (CART) score thresholds a priori from which to measure time to RRT activation (CART score ≥ 12, ≥ 16, ≥ 20, and ≥ 24). The primary outcome was 7-day mortality-death or discharge to hospice care within 7 days of RRT activation. For each CART threshold, we modeled the association of time to RRT activation duration with 7-day mortality using multivariable fractional polynomial regression. Increased time from clinical decompensation to RRT activation was associated with higher risk of 7-day mortality. This relationship was nonlinear, with odds of mortality increasing rapidly as time to RRT activation increased from 0 to 4 hours and then plateauing. This pattern was observed across several thresholds of physiologic derangement. CONCLUSIONS:Increasing time to RRT activation was associated in a nonlinear fashion with increased 7-day mortality. This relationship appeared most marked when using a CART score greater than 20 threshold from which to measure time to RRT activation. We suggest that these empirical findings could be used to inform RRT delay definitions in further studies to determine the clinical impact of interventions focused on timely RRT activation.

show abstract

Section: Discussionmentioning

confidence: 99%

Association of Time to Rapid Response Team Activation With Patient Outcomes Using a Range of Physiologic Deterioration Thresholds

Mitchell

Neefe

Ginestra

et al. 2022

Critical Care Explorations

View full text Add to dashboard Cite

show abstract

“…The respiratory rate has previously been found as one of the key parameters in predicting patient at a risk of acute death 8 9 27–29. In some subcohorts, such as patients with COVID-19 and patients reviewed by hospitals’ rapid response teams, abnormal haemodynamic parameters have not been associated with morbidity at all or they have represented in late phase of deterioration, whereas abnormal respiratory parameters have reliably discriminated patients at risk 7 10. In general, studies across a variety of different settings have somewhat consistently found that of individual vital signs, the respiratory rate, the blood pressure and the level of consciousness are more strongly associated with mortality as compared with the heart rate and the blood oxygen saturation 26 30–32.…”

Section: Discussionmentioning

confidence: 99%

“…EWS vital sign components have been considered equal, as in using plain statistical percentiles to define score categories for each vital sign, for example 6. However, some studies suggest that the respiratory parameters may be more strongly associated with morbid patient outcomes 7–10. This phenomenon, however, has not been thoroughly investigated among mixed general ward patients.…”

Section: Introductionmentioning

confidence: 99%

Ability of the National Early Warning Score and its respiratory and haemodynamic subcomponents to predict short-term mortality on general wards: a prospective three-centre observational study in Finland

et al. 2022

Self Cite

View full text Add to dashboard Cite

ObjectivesTo validate the ability of the National Early Warning Score (NEWS) to predict short-term mortality on hospital wards, with a special reference to the NEWS’s respiratory and haemodynamic subcomponents.DesignA large, 1-year, prospective, observational three-centre study. First measured vital sign datasets on general wards were prospectively collected using a mobile solution system during routine patient care. Area under receiver operator characteristic curves were constructed, and comparisons between ROC curves were conducted with Delong’s test for two correlated ROC curves.SettingOne university hospital and two regional hospitals in Finland.ParticipantsAll 19 001 adult patients admitted to 45 general wards in the three hospitals over the 1-year study period. After excluding 102/19 001 patients (0.53%) with data on some vital signs missing, the final cohort consisted of 18 889 patients with full datasets.Primary and secondary outcome measuresThe primary outcome measure was 1-day mortality and secondary outcomes were 2-day and 30-day mortality rates.ResultsPatients’ median age was 70 years, 51% were male and 31% had a surgical reason for admission. The 1-day mortality was 0.36% and the 30-day mortality was 3.9%. The NEWS discriminated 1-day non-survivors with excellent accuracy (AUROC 0.91, 95% CI 0.87 to 0.95) and 30-day mortality with acceptable accuracy (0.75, 95% CI 0.73 to 0.77). The NEWS’s respiratory rate component discriminated 1-day non-survivors better (0.78, 95% CI 0.72 to 0.84) as compared with the oxygen saturation (0.66, 95% CI 0.59 to 0.73), systolic blood pressure (0.65, 95% CI 0.59 to 0.72) and heart rate (0.67, 95% CI 0.61 to 0.74) subcomponents (p<0.01 in all ROC comparisons). As with the total NEWS, the discriminative performance of the individual score components decreased substantially for the 30-day mortality.ConclusionsNEWS discriminated general ward patients at risk for acute death with excellent statistical accuracy. The respiratory rate component is especially strongly associated with short-term mortality.Trial registration numberNCT04055350.

show abstract

“…This is often the junior doctor who then needs to attend, assess and then also make a decision about whether or not to escalate the issue to the next person in the hierarchy. This is important because, for the most, the junior doctor does not have the skills or emotional intelligence to appropriately manage a lot of these clinical abnormalities [32][33][34][35]. If the issue is escalated, it is often to a middle grade doctor, one who is often a specialist in training and who as such may be difficult to find.…”

Section: Clinical Futile Cycles and The Traditional Hierarchical Refe...mentioning

confidence: 99%

Clinical Futile Cycles: Systematic Microeconomic Reform of Health Care by Reform of the Traditional Hierarchical Referral Model of Care

Buist¹,

Arnold²

2023

Contemporary Topics in Patient Safety - Volume 2

View full text Add to dashboard Cite

The incidence of adverse patient events in hospitals has not improved over the last two decades despite enormous efforts in the area of Quality and Safety. Notably, the same errors are often repeated, even though previous reviews of these events have resulted in learnings, guidelines and policy. The traditional review of a Hospital Adverse Event (HAE) is most commonly a Root Cause Analysis (RCA) to find factors and conditions that caused or contributed to the HAE. The basis for the RCA is the James Reason Swiss Cheese model of adverse events developed from analysis of large- scale industrial accidents. In this model the HAE occurs when a patient deteriorating clinical trajectory broaches the hospital’s organisational and professional defences. The learnings from the RCA typically result in new or changed policies and procedures, and occasionally professional disciplinary review of the involved health care workers. Clinical Futile Cycles (CFC) is clinical action or intervention (or lack thereof) that has no patient benefit. Analysis of HAE by looking for CFC creates learnings that focus on the human factors of the involved health care workers, and more importantly the socio, politico, and fiscal cultural hospital environment at the time of the HAE. As such, the learnings focus not on limitations of the individual practitioners but rather, the greater environment that has them often ignoring, broaching or being oblivious to professional standards, and the already existent policy procedure and guidelines.

show abstract

Afferent limb failure revisited – A retrospective, international, multicentre, cohort study of delayed rapid response team calls

Cited by 23 publications

References 35 publications

Association of Time to Rapid Response Team Activation With Patient Outcomes Using a Range of Physiologic Deterioration Thresholds

Association of Time to Rapid Response Team Activation With Patient Outcomes Using a Range of Physiologic Deterioration Thresholds

Ability of the National Early Warning Score and its respiratory and haemodynamic subcomponents to predict short-term mortality on general wards: a prospective three-centre observational study in Finland

Clinical Futile Cycles: Systematic Microeconomic Reform of Health Care by Reform of the Traditional Hierarchical Referral Model of Care

Contact Info

Product

Resources

About