“Deterioration to Door Time”: An Exploratory Analysis of Delays in Escalation of Care for Hospitalized Patients

Sankey, Christopher; McAvay, Gail; Siner, Jonathan; Barsky, Carol L.; Chaudhry, Sarwat I.

doi:10.1007/s11606-016-3654-x

Cited by 39 publications

(21 citation statements)

References 36 publications

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“…A subgroup subsequently required early escalation to PICU care (12.8%). These patients had a longer PICU length of stay compared to floor patients with deterioration transferred directly to the PICU, consistent with prior literature demonstrating that delays in ICU transfer for hospitalized patients with critical illness result in high mortality and longer ICU LOS . These findings highlight the importance of appropriate triage of patients with clinical deterioration to IMCU versus PICU level of care to improve overall hospital outcomes.…”

Section: Discussionsupporting

confidence: 85%

Pediatric Early Warning Systems aid in triage to intermediate versus intensive care for pediatric oncology patients in resource‐limited hospitals

Agulnik

Nadkarni

Robles³

et al. 2018

Pediatric Blood & Cancer

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Pediatric oncology patients hospitalized in resource-limited settings are at high risk for clinical deterioration resulting in mortality. Intermediate care units (IMCUs) provide a cost-effective alternative to pediatric intensive care units (PICUs). Inappropriate IMCU triage, however, can lead to poor outcomes and suboptimal resource utilization. In this study, we sought to characterize patients with clinical deterioration requiring unplanned transfer to the IMCU in a resource-limited pediatric oncology hospital. Patients requiring subsequent early PICU transfer had longer PICU length of stay. PEWS results prior to IMCU transfer were higher in patients requiring early PICU transfer, suggesting PEWS can aid in triage between IMCU and PICU care.

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Section: Discussionsupporting

confidence: 85%

Pediatric Early Warning Systems aid in triage to intermediate versus intensive care for pediatric oncology patients in resource‐limited hospitals

Agulnik

Nadkarni

Robles³

et al. 2018

Pediatric Blood & Cancer

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“…Finally, we can only speculate that the long duration of abnormal vital signs prior to CD suggests these events are potentially preventable through earlier intervention. However, there is an abundance of evidence that delays in ICU transfer for patients with clinical changes increases mortality (1)(2)(3)(4)12), and it is reasonable to hypothesize that earlier identification, intervention, and PICU transfer would in turn improve outcomes. This conclusion would need testing through prospective studies evaluating the implementation of PEWS or other systems to guide ERS activation in this high-risk patient population.…”

Section: Resultsmentioning

confidence: 99%

“…Delays in Intensive Care Unit (ICU) transfer for critically ill hospitalized patients have been consistently linked with worse outcomes including increasing organ dysfunction, longer ICU length of stay (LOS), and higher hospital mortality (1)(2)(3)(4). Since the launch of the Institute for Healthcare Improvement's 100,000 Lives Campaign in 2004 (5,6), timely identification of deterioration in hospitalized patients and appropriate activation of Emergency Response Systems (ERSs) has been an important element of hospital programs to reduce preventable harm and hospital mortality.…”

Section: Introductionmentioning

confidence: 99%

Abnormal Vital Signs Predict Critical Deterioration in Hospitalized Pediatric Hematology-Oncology and Post-hematopoietic Cell Transplant Patients

et al. 2020

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Introduction: Hospitalized pediatric hematology-oncology and post-hematopoietic cell transplant (HCT) patients have frequent deterioration requiring Pediatric Intensive Care Unit (PICU) care. Critical deterioration (CD), defined as unplanned PICU transfer requiring life-sustaining interventions within 12 h, is a pragmatic metric to evaluate emergency response systems (ERS) in pediatrics, however, it has not been investigated in these patients. The goal of this study was to evaluate if CD is an appropriate metric to assess effectiveness of ERS in pediatric hematology-oncology and post-HCT patients and if it is preceded by an actionable period of vital sign changes. Methods: A retrospective review of all unplanned PICU transfers and floor cardiopulmonary arrests in a dedicated pediatric hematology-oncology hospital between August 2014 and July 2016. Vital signs and physical exam findings 48 h prior to events were converted to Pediatric Early Warning System-Like Scores (PEWS-LS) using cardiovascular, respiratory, and neurologic criteria. Results: There were 220 deterioration events, with 107 (48.6%) meeting criteria for CD, representing a rate of 2.98 per 1,000-inpatient-days. Using the first event per hospitalization (n = 184), patients with CD had higher mortality (17.4 vs. 7.6%, p = 0.045), fewer median ICU-free-days (21 vs. 24, p = 0.011), ventilator-free-days (25 vs. 28, p < 0.001), and vasoactive-free-days (27 vs. 28, p < 0.001). Using vital sign data 48 h prior to deterioration events, those with CD had higher PEWS-LS on PICU admission (p < 0.001), spent more time with elevated PEWS-LS prior to PICU transfer (p = 0.008 to 0.023) and had a longer time from first abnormal PEWS-LS (p = 0.007 to 0.043). Significant difference between the two groups was observed as early as 4 h prior to the event (p = 0.047). Conclusion: Hospitalized pediatric hematology-oncology and post-HCT patients have frequent deterioration resulting in a high mortality. In these patients, CD is over 13 times Agulnik et al. Critical Deterioration in Pediatric Oncology more common than floor cardiopulmonary arrests and associated with higher mortality and fewer event-free days, making it a useful metric in these patients. CD is preceded by a long duration of abnormal vital signs, making it potentially preventable through earlier recognition.

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“…5,6 Time is essential, as delayed management has been associated with increase mortality. 7,8 Two previous systematic reviews 5,9 have found moderate-strength evidence that implementation of RRS is associated with reduced rates of cardiac arrest and mortality. However, because many RRS fail to provide appropriate outcomes, there is debate about their effectiveness, and how to evaluate them.…”

Section: Introductionmentioning

confidence: 99%

Succeeding with rapid response systems – a never-ending process: A systematic review of how health-care professionals perceive facilitators and barriers within the limbs of the RRS

et al. 2019

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Background: Meta-analyses show that hospital rapid response systems (RRS) are associated with reduced rates of cardiorespiratory arrest and mortality. However, many RRS fail to provide appropriate outcomes. Thus an improved understanding of how to succeed with a RRS is crucial. By understanding the barriers and facilitators within the limbs of a RRS, these can be addressed.Objective: To explore the barriers and facilitators within the limbs of a RRS as described by health-care professionals working within the system. Methods:The electronic databases searched were: EMBASE, MEDLINE, CINAHL, Epistemonikos, Cochrane, PsychInfo and Web of Science. Search terms were related to RRS and their facilitators and barriers. Studies were appraised guided by the CASP tool. Twenty-one qualitative studies were identified and subjected to content analysis.Results: Clear leadership, interprofessional trust and collaboration seems to be crucial for succeeding with a RRS. Clear protocols, feedback, continuous evaluation and interprofessional training were highlighted as facilitators. Reprimanding down the hierarchy, underestimating the importance of call-criteria, alarm fatigue and a lack of integration with other hospital systems were identified as barriers. Conclusion:To succeed with a RRS, the keys seem to lie in the administrative and quality improvement limbs. Clear leadership and continuous quality improvement provide the foundation for the continuing collaboration to manage deteriorating patients. Succeeding with a RRS is a never-ending process.

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“Deterioration to Door Time”: An Exploratory Analysis of Delays in Escalation of Care for Hospitalized Patients

Cited by 39 publications

References 36 publications

Pediatric Early Warning Systems aid in triage to intermediate versus intensive care for pediatric oncology patients in resource‐limited hospitals

Pediatric Early Warning Systems aid in triage to intermediate versus intensive care for pediatric oncology patients in resource‐limited hospitals

Abnormal Vital Signs Predict Critical Deterioration in Hospitalized Pediatric Hematology-Oncology and Post-hematopoietic Cell Transplant Patients

Succeeding with rapid response systems – a never-ending process: A systematic review of how health-care professionals perceive facilitators and barriers within the limbs of the RRS

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