Medical intensive care unit consults occurring within 48 hours of admission: A prospective study

Cohen, Rubin I.; Eichorn, Ann; Motschwiller, Caroline; Laktikova, Viera; Torre, Grace La; Ginsberg, Nicole; Steinberg, Harry

doi:10.1016/j.jcrc.2014.11.001

Cited by 15 publications

(14 citation statements)

References 13 publications

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“…However, in a previous study, we examined just this population and found similar results. 8 Indeed, our purpose of examining RRT activation rather than ICU consults was to more adequately capture early deterioration. It is also possible that some patients had a change in code status to DNR, and as such the RRT was not activated.…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, in a previous study we prospectively assessed all ICU consults requested within 48 hours of admission to determine factors associated with early deterioration. 8 However, our prior study, as well as those of others, cannot account for patients who experienced an adverse event and on whom an ICU consult was not requested. More importantly, prior studies did not evaluate early deterioration in the present-day context of the rapid response team (RRT).…”

Section: Introductionmentioning

confidence: 90%

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Early in-hospital clinical deterioration is not predicted by severity of illness, functional status, or comorbidity

Wang¹,

Hahn²,

Kline³

et al. 2017

IJGM

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BackgroundPrior studies concentrated on unplanned intensive care unit (ICU) transfer to gauge deterioration occurring shortly following hospital admission. However, examining only ICU transfers is not ideal since patients could stabilize with treatment, refuse ICU admission, or not require ICU evaluation. To further explore etiologies of early clinical deterioration, we used rapid response team (RRT) activation within 48 hours of admission as an index of early clinical worsening.MethodsA retrospective analysis of prospectively gathered admissions from the emergency department in an academic medical center was done. Data were reviewed independently by two physicians. We assessed severity of illness, functional status, comorbidity, the frequency of ICU and palliative care consultations, and changes in advance health care directives.ResultsOf 655 rapid responses (RRs) within the study period, 24.6% occurred within 48 hours of admission. Disease trajectory was the most frequent perceived reason for RRs (55.6% and 58.9%, reviewer 1 and 2, respectively) followed by medical error (15.6% and 15.2%). Acute physiology and chronic health evaluation II (APACHE-II) and modified early warning scores (MEWS) were higher at the time of RR compared to admission (p<0.0001). However, admission APACHE-II, MEWS, functional status, and comorbidity scores did not predict early RRs. One third of RRs resulted in ICU consultation and 95% were accepted. Palliative care consults were requested for 15%, the majority (65%) after RR and all resulting in advance directive change.ConclusionDisease trajectory accounted for most clinical deterioration and medical error contributed to 15%. Our data suggest that it is difficult to predict early clinical deterioration as none of the measured parameters were associated with RRT activation.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 90%

Early in-hospital clinical deterioration is not predicted by severity of illness, functional status, or comorbidity

Wang¹,

Hahn²,

Kline³

et al. 2017

IJGM

View full text Add to dashboard Cite

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“…9 This cohort of patients frequently have acute respiratory failure requiring EEI. 10,11 In addition to more profound severity of illness, patients who require EEI outside an ICU may be less likely to have adequate intravenous access or be more likely to have gastric contents putting them at risk for aspiration. 12 Although multiple studies have described the patient populations and outcomes following EEI inside an ICU, 2,4 there have been few publications describing EEI outside an ICU.…”

Section: Introductionmentioning

confidence: 99%

Impact of a Critical Care Specialist Intervention on First Pass Success for Emergency Airway Management Outside the ICU

Fein

Mastroianni

Murphy

et al. 2019

J Intensive Care Med

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Background: There has been limited investigation into the procedural outcomes of patients undergoing emergent endotracheal intubation (EEI) by a critical care medicine (CCM) specialist outside the intensive care unit (ICU). We hypothesized that EEI outside an ICU would be associated with lower rates of first pass success (FPS) as compared to inside an ICU. Methods: We performed a retrospective cohort study of all adult patients admitted to our academic medical center between January 1, 2016, and July 31, 2018, who underwent EEI by a CCM practitioner. The primary outcome of FPS was identified in the EEI procedure note. Secondary outcomes included difficult intubation (> 2 attempts at laryngoscopy) and mortality following EEI. Results: In total, 1958 patients (1035 [52.9%] inside ICU and 923 [47.1%]) outside an ICU) were included in the final cohort. Unadjusted rate of FPS was not different between patients intubated out of the ICU and patients intubated inside of the ICU (689 [74.7%] vs 775 [74.9%]; P = .91). There was also no difference in FPS between groups after adjusting for predictors of difficult intubation and baseline covariates (odds ratio: 0.95; 95% confidence interval, 0.75-1.2, P = .65). Mortality of patients undergoing EEI out of the ICU was higher at each examined time interval following EEI. Discussion: For EEI done by CCM practitioners, rate of FPS is not different between patients undergoing EEI outside an ICU as compared to inside an ICU. Despite the lack of difference between rates of procedural success, patient mortality following EEI outside an ICU is higher than EEI inside an ICU at all examined time points during hospitalization.

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“…34 Clinicians know, though, that there are many paths to clinical deterioration. For example, the most common forms of deterioration leading to ICU transfer are respiratory instability, [35][36][37][38][39][40][41] hemodynamic instability 35,38,39 , sepsis 40,42 , bleeding 38,42 , neurological decompensation 42 , unplanned surgery 38 , and acute renal failure or electrolyte abnormalities. 42 The multiplicity of candidate culprit organ systems suggests that a single model is not likely to catch all the patients who are worsening.…”

Section: Introductionmentioning

confidence: 99%

Early detection of in-patient deterioration: one prediction model does not fit all

Blackwell

Keim‐Malpass

Clark

et al. 2020

Preprint

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Objectives: Early detection of subacute potentially catastrophic illnesses using available data is a clinical imperative, and scores that report risk of imminent events in real time abound. Patients deteriorate for a variety of reasons, and it is unlikely that a single predictor such as an abnormal National Early Warning Score (NEWS) will detect all of them equally well. The objective of this study was to test the idea that the diversity of reasons for clinical deterioration leading to ICU transfer mandates multiple targeted predictive models. Design: Individual chart review to determine the clinical reason for ICU transfer; determination of relative risks of individual vital signs, lab tests and cardiorespiratory monitoring measures for prediction of each clinical reason for ICU transfer; logistic regression modeling for the outcome of ICU transfer for a specific clinical reason. Setting: Cardiac medical-surgical ward; tertiary care academic hospital. Patients: 8111 adult patients, 457 of whom were transferred to an ICU for clinical deterioration. Interventions: None. Measurements and main results: We calculated the contributing relative risks of individual vital signs, lab tests and cardiorespiratory monitoring measures for prediction of each clinical reason for ICU transfer, and used logistic regression modeling to calculate ROC areas and relative risks for the outcome of ICU transfer for a specific clinical reason. The reasons for clinical deterioration leading to ICU transfer were varied, as were their predictors. For example, the three most common reasons - respiratory instability, infection and suspected sepsis, and heart failure requiring escalated therapy - had distinct signatures of illness. Statistical models trained to target specific reasons for ICU transfer performed better than one model targeting combined events, and both performed better than the untrained NEWS score. Conclusions and relevance: A single predictive model for clinical deterioration does not perform as well as having multiple models trained for the individual specific clinical events leading to ICU transfer.

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Medical intensive care unit consults occurring within 48 hours of admission: A prospective study

Cited by 15 publications

References 13 publications

Early in-hospital clinical deterioration is not predicted by severity of illness, functional status, or comorbidity

Early in-hospital clinical deterioration is not predicted by severity of illness, functional status, or comorbidity

Impact of a Critical Care Specialist Intervention on First Pass Success for Emergency Airway Management Outside the ICU

Early detection of in-patient deterioration: one prediction model does not fit all

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