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Aim: To analyse the qualitative evidence on the role of critical care nurses in rapid response teams. Design: Qualitative systematic review. Methods: This qualitative systematic review employed Bettany‐Saltikov and McSherry's guidelines and is reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research checklist. Two pairs of blinded researchers screened the articles. The data were synthesised using a thematic analysis approach. Data Sources: A systematic literature search was conducted using the CINAHL, Embase and MEDLINE databases. Results: Seven studies were included, and three main roles were identified: (1) balancing between confidence and fear in clinical encounters, (2) facilitating collaboration and (3) managing challenging power dynamics in decision‐making. Conclusion: Critical care nurses possess extensive knowledge and skills in providing critical care to patients experiencing deterioration on general wards. They play a vital role in facilitating collaboration between team members and ward staff. Furthermore, within the rapid response team, critical care nurses assume leadership responsibilities by overseeing the comprehensive coordination of patient care and actively engaging in the decision‐making process concerning patient care. Implications for the Profession: Highlighting the central role of critical care nurses in rapid response teams as well such a team's benefits in healthcare organisations can promote applications for funding to support further quality assurance of rapid response teams and thus enhance patient safety. Impact: Health care organisations can assure the quality of rapid response team by providing economical resources and training. The education providers should facilitate and standardise curriculum for critical care nursing students to achieve necessary knowledge and skills as members in rapid response teams. Patient or Public Contribution: No patient or public contribution. [ABSTRACT FROM AUTHOR]

Objective: The COVID‐19 pandemic has had a substantial impact on the utilisation of hospital and emergency department (ED) services. We examined the effect of a rapid response service on hospital re‐presentations among people discharged from the ED and short‐stay wards at a tertiary referral hospital. Methods: This retrospective cohort study compared 112 patients who completed the Care in the Community program with 112 randomly selected controls. Both cases and controls were discharged from hospital between September 2020 and June 2021. Intervention patients were evaluated by a multidisciplinary team, who implemented a goal‐directed program of up to 4‐weeks duration. Logistic regression, negative binomial regression and Cox proportional hazards regression were used to evaluate outcomes at 28 days and at 6 months. Results: The median time between referral and the first home visit was 3.9 days. In adjusted analyses, the intervention reduced hospital re‐presentations at 28 days (odds ratio:.40, 95% confidence interval (CI):.17–.94) and lengthened the time to the first hospital re‐presentation (hazard ratio:.59, 95% CI:.38–.92). Although the intervention did not reduce the total number of hospital re‐presentations at 6 months (adjusted incidence rate ratio:.73, 95% CI:.49–1.08), it reduced total time spent in hospital by 303 days (582 vs. 885). Conclusions: This study is among the first to investigate the effect of a community‐based intervention on hospital re‐presentations during the COVID‐19 pandemic. It provides evidence that a sustainable 4‐week intervention is associated with reduced hospital re‐presentations and time spent in hospital. [ABSTRACT FROM AUTHOR]

Background: Navigating medical care at the end of life can be a challenging experience for patients. There are also significant resource burdens, including intensive care unit (ICU) admissions, accompanying terminal illness. For actively dying patients, developing a care plan based on patient goals and delivering care at the bedside can enhance patient well-being, avoid inappropriate transfers or interventions, and improve resource management. Methods: The Rapid Response Team (RRT) is an around the clock intensivist service that responds to all acutely decompensating patients in our hospital. Through the Appropriate Care Escalation (ACE) program, the RRT intensivist identifies amongst decompensating patients, terminally ill individuals for whom prognosis is extremely poor irrespective of available interventions. These patients receive discussions about goals of care, code status, and management options. They receive care on a dedicated stepdown unit without escalation to the ICU. If aligned with patient goals, care plans incorporate critical care interventions including ventilator and vasopressor therapy. Results: Over 5 years, RRT identified 413 terminally ill patients under the ACE program to continue end of life care on the stepdown unit. Following discussions of goals, 60.8% of patients requested DNR/DNI, 30.9% were full code, and 8.5% requested DNR/OK-TO-INTUBATE status. At discharge, 82.1% of ACE patients expired compared to 23% of all RRT consultations. Patients received 233 critical care procedures at bedside including intubations, central access catheters and bronchoscopy. Conclusion: The ACE program helped identify, in real time, actively dying, terminally ill patients, establish patient goals, and expand critical care services outside the ICU. [ABSTRACT FROM AUTHOR]

Rapid Response Teams (RRTs) are multidisciplinary, 'hospital at home' services which have developed over the last 10 years, aiming to improve recovery from illness more efficiently, prevent unnecessary hospital admission, and prevent early admission to residential care. However, little is known about the experience of professionals working in these roles. The aim of this study was to explore how working in an RRT is experienced and perceived by physiotherapists. This study used phenomenographically inspired methodology. Six participants who were working in RRTs were recruited to this study and all were working in the South of England. Data were collected via semi-structured interviews, and phenomenographic analysis was undertaken. Participants working in RRTs described a range of varied, concrete lived-through experiences in addition to a more rhetorical discussion of how they conceptualized their work. Six main categories of description were generated from the analysis; each was assigned a metaphor. These included 'the detective,' 'the guru,' 'the lone ranger,' 'the team player,' 'the bricoleur,' and 'an emotional rollercoaster'; all categories were present with varied meanings. 'An emotional rollercoaster' was present within and throughout participants' descriptions of all other categories. This study provides valuable insights into physiotherapists' experience and conceptualization of working within this discipline, which may have implications for physiotherapy practice, workforce development, new and current RR physiotherapy services, RRT health professionals, and physiotherapy education. [ABSTRACT FROM AUTHOR]

Background and Aims: Vital sign monitoring needs to be timely and correct to recognize deteriorating patients early and trigger the relevant clinical response. The aim of this study is to retrospectively evaluate compliance specifically toward the regional vital sign monitoring protocol the so called early warning score protocol (EWS‐protocol) 72 h before a medical emergency team response (MET‐response) and thereby illuminate whether poor compliance translates into a worse patient outcome. Methods: It was investigated all eligible patients that underwent MET responses during the calendar year 2019. The inclusion criteria encompassed somatic patients above 18 years of age admitted to the hospital and detailed evaluations of the medical records of the included patients were conducted. Results: Four hundred and twenty‐nine MET‐responses were included in the final analysis. EWS‐protocol failure was observed for more than half the patients within all the time frames assessed. Thirty‐day mortality was significantly higher for patients subject to EWS protocol failure in the timeframes 24−16, 16−8, 8−0 h before MET response. Adjusting for admission length, age, and gender, patients subject to EWS‐protocol failure had an odds ratio (OR) of 1.9, 2.0, 2.1, 2.3 for mortality in the time frames 72−48, 24−16, 16−8, and 8−0 h before the MET‐response, respectively. The adjusted OR for ICU‐admission was 1.7, and 1.6 for patients subject to EWS‐protocol failure in the time frames 16−8 and 8−0 h before MET‐response, respectively. Conclusion: According to all the data analysis in this article, there is evidence that compliance toward the NEWS‐protocol is poor. EWS‐protocol failure is associated with a significant higher mortality and ICU‐admission rate. [ABSTRACT FROM AUTHOR]

This retrospective study assessed the effectiveness and impact of implementing a Modified Early Warning System (MEWS) and Rapid Response Team (RRT) for inpatients admitted to the general ward (GW) of a medical center. This study included all inpatients who stayed in GWs from Jan. 2017 to Feb. 2022. We divided inpatients into GWnon-MEWS and GWMEWS groups according to MEWS and RRT implementation in Aug. 2019. The primary outcome, unexpected deterioration, was defined by unplanned admission to intensive care units. We defined the detection performance and effectiveness of MEWS according to if a warning occurred within 24 h before the unplanned ICU admission. There were 129,039 inpatients included in this study, comprising 58,106 GWnon-MEWS and 71,023 GWMEWS. The numbers of inpatients who underwent an unplanned ICU admission in GWnon-MEWS and GWMEWS were 488 (.84%) and 468 (.66%), respectively, indicating that the implementation significantly reduced unexpected deterioration (p <.0001). Besides, 1,551,525 times MEWS assessments were executed for the GWMEWS. The sensitivity, specificity, positive predicted value, and negative predicted value of the MEWS were 29.9%, 98.7%, 7.09%, and 99.76%, respectively. A total of 1,568 warning signs accurately occurred within the 24 h before an unplanned ICU admission. Among them, 428 (27.3%) met the criteria for automatically calling RRT, and 1,140 signs necessitated the nursing staff to decide if they needed to call RRT. Implementing MEWS and RRT increases nursing staff's monitoring and interventions and reduces unplanned ICU admissions. [ABSTRACT FROM AUTHOR]

The aim of this study is to assess WHO/Eastern Mediterranean region (WHO/EMR) countries capacities, operations and outbreak response capabilities. Cross-sectional study was conducted targeting 22 WHO/EMR countries from May to June 2021. The survey covers 8 domains related to 15 milstones and key performance indicators (KPIs) for RRT. Responses were received from 14 countries. RRTs are adequately organised in 9 countries (64.3%). The mean retention rate of RRT members was 85.5% ± 22.6. Eight countries (57.1%) reported having standard operating procedures, but only three countries (21.4%) reported an established mechanism of operational fund allocation. In the last 6 months, 10,462 (81.9%) alerts were verified during the first 24 h. Outbreak response was completed by the submission of final RRT response reports in 75% of analysed outbreaks. Risk Communication and Community Engagement (RCCE) activities were part of the interventional response in 59.5% of recent outbreaks. Four countries (28.6%) reported an adequate system to assess RRTs operations. The baseline data highlights four areas to focus on: developing and maintaining the multidisciplinary nature of RRTs through training, adequate financing and timely release of funds, capacity and system building for implementing interventions, for instance, RCCE, and establishing national monitoring and evaluation systems for outbreak response. [ABSTRACT FROM AUTHOR]

Aim: To explore hospital managers' perceptions of the Rapid Response Team. Design: An explorative qualitative study using semi‐structured individual interviews. Methods: In September 2019, a qualitative interview study including nineteen hospital managers at three managerial levels in acute care hospitals was conducted. Interview transcripts were analysed with an inductive content analysis approach, involving researcher triangulation in data collection and analysis processes. Findings: One theme, 'A resource with untapped potential, enhancing patient safety, high‐quality nursing, and organisational cohesion' was identified and underpinned by six categories and 30 sub‐categories. Conclusion: The Rapid Response Team has an influence on the organization that goes beyond the team's original purpose. It strengthens the organization's dynamic cohesion by providing clinical support to nurses and facilitating learning, communication and collaboration across the hospital. Managers lack engagement in the team, including local key data to guide future quality improvement processes. Implications: For organizations, nursing, and patients to benefit from the team to its full potential, managerial engagement seems crucial. Impact: This study addressed possible challenges to using the Rapid Response Team optimally and found that hospital managers perceived this complex healthcare intervention as beneficial to patient safety and nursing quality, but lacked factual insight into the team's deliverances. The research impacts patient safety pointing at the need to re‐organize managerial involvement in the function and development of the Rapid Response Team and System. Reporting Method: We have adhered to the COREQ checklist when reporting this study. "No Patient or Public Contribution" [ABSTRACT FROM AUTHOR]

Background: In‐hospital cardiac arrest (IHCA) affects approximately 3000 patients annually in Australia. Introduction of the National Standard for Deteriorating Patients in 2011 was associated with reduced IHCA‐related intensive care unit (ICU) admissions and reduced in‐hospital mortality of such patients. Aims: To assess whether the reduction in IHCA‐related ICU admissions from hospital wards seen following the implementation of the national standard (baseline period 2013–2014) was sustained over the follow‐up period (2015–2019) in Australia. Methods: A multi‐centre retrospective cohort study to compare the characteristics and outcomes of IHCA admitted to the ICU between baseline and follow‐up periods. The primary outcome was the proportion of patients admitted to ICU from the ward following IHCA. Secondary outcomes included ICU and hospital mortality of IHCA‐related ICU admissions. Data were analysed using hierarchical multivariable logistic regression. Results: The proportion of cardiac arrest‐related admissions from the ward was lower in the follow‐up period when compared to baseline (4.1 vs 3.8%; P = 0.04). Such patients had lower illness severity and were more likely to have limitations of medical treatment at admission. However, after adjustment for severity of illness, the likelihood of being admitted to ICU following cardiac arrest on the ward increased in the follow‐up period (odds ratio (OR) 1.13 (1.05–1.22); P = 0.001). Hospital mortality was lower in the follow‐up period (50.3 vs 46.3%; P = 0.02), but after adjustment the likelihood of death did not differ between the periods (OR 1.0 (0.86–1.17); P = 0.98). Conclusion: After adjustment for the severity of illness, the likelihood of being admitted to ICU after IHCA slightly increased in the follow‐up period. [ABSTRACT FROM AUTHOR]

Continuous vital sign monitoring (CM) may detect ward patient’s deterioration earlier than periodic monitoring. This could result in timely ICU transfers or in a transfer delay due to misperceived higher level of care on the ward. The primary objective of this study was to compare patient’s disease severity upon unplanned ICU transfer, before and after CM implementation. We included a one-year period before and after CM implementation between August 1, 2017 – July 31, 2019. Before implementation, surgical and internal medicine patients’ vital signs were periodically monitored, compared to continuous monitoring with wireless linkage to hospital systems after implementation. In both periods the same early warning score (EWS) protocol was in place. Primary outcome was disease severity scores upon ICU transfer. Secondary outcomes were ICU and hospital length of stay, incidence of mechanical ventilation and ICU mortality. In the two one-year periods 93 and 59 unplanned ICU transfer episodes were included, respectively. Median SOFA (3 (2–6) vs 4 (2–7), p =.574), APACHE II (17 (14–20) vs 16 (14–21), p =.824) and APACHE IV (59 (46–67) vs 50 (36–65), p =.187) were comparable between both periods, as were the median ICU LOS (3.0 (1.7–5.8) vs 3.1 (1.6–6.1), p.962), hospital LOS (23.6 (11.5–38.0) vs 19 (13.9–39.2), p =.880), incidence of mechanical ventilation (28 (47%) vs 22 (54%), p.490), and ICU mortality (11 (13%) vs 10 (19%), p.420). This study shows no difference in disease severity upon unplanned ICU transfer after CM implementation for patients who have deteriorated on the ward. [ABSTRACT FROM AUTHOR]

Purpose: The Ramathibodi Rapid Response System (RRRS), implemented in March 2017, aims to identify and respond to patients with deteriorating conditions outside the ICU. It employs the Ramathibodi early warning score and clinical signs to monitor all admitted patients, providing expert physician monitoring and early treatment for stabilization and appropriate care triage. This study assesses the RRRS's effectiveness in reducing in-hospital mortality and CPR events outside the ICU.Patients and Methods: We conducted a retrospective observational study from March 2014 to February 2020 in a tertiary care hospital's general wards. We included adult patients experiencing unplanned ICU admission, sudden cardiac arrest, or unexpected death. The study compared in-hospital mortality and CPR incidence outside the ICU between pre- and post-RRRS implementation groups. The associations between RRRS implementation and in-hospital mortality and the incidence of CPR outside the ICU were assessed using multiple logistic regression analyses.Results: We evaluated 17,741 admissions, with 9168 before RRRS implementation (1 March 2014 to 28 February 2017) and 8573 after RRRS implementation (1 March 2017 to 29 February 2020). The implementation of RRRS was associated with a significant reduction in in-hospital mortality, which decreased from 30.0% to 20.8% (odds ratio, 0.62; 95% confidence interval [CI], 0.57 to 0.66; P< 0.0001). Even after adjusting for age, sex, and comorbidities, the reduction in in-hospital mortality remained significant (adjusted odds ratio, 0.58; 95% CI, 0.54 to 0.63; P< 0.0001). The incidence of CPR outside the ICU also decreased from 1.8% to 1.1% (adjusted odds ratio, 0.6; 95% CI, 0.46 to 0.77; P< 0.0001). Additionally, the rate of ICU transfer increased from 85.4% to 92.1% (risk difference, 6.7; 95% CI, 7.6 to 5.8; P< 0.0001) after implementing the RRRS.Conclusion: Implementing the RRRS is associated with a reduction in in-hospital mortality and the incidence of CPR outside the ICU. [ABSTRACT FROM AUTHOR]

Dedicated rapid response teams are created to prevent clinical decline. In a review of medical records, authors examined cardio-pulmonary arrest and activation rates over 3 years following implementation of a dedicated response team. A significant decrease in cardiopulmonary arrests and increased activations was found. [ABSTRACT FROM AUTHOR]

Background: The outcomes of rapid response systems (RRS) are poorly established in older people. We examined the outcomes in older inpatients at a tertiary hospital that uses a 2-tier RRS, including the outcomes of each tier. Methods: The 2-tier RRS comprised the clinical review call (CRC) (tier one) and the medical emergency team call (MET) (tier two). We compared the outcomes in four configurations of MET and CRC (MET with CRC; MET without CRC; CRC without MET; neither MET nor CRC). The primary outcome was in-hospital death, and secondary outcomes were length of stay (LOS) and new residential facility placement. Statistical analyses were carried out using Fisher's exact tests, Kruskal-Wallis tests, and logistic regression. Results: A total of 433 METs and 1,395 CRCs occurred among 3,910 consecutive admissions of mean age 84 years. The effect of a MET on death was unaffected by the occurrence of a CRC. The rates of death for MET ± CRC, and CRC without MET, were 30.5% and 18.5%, respectively. Patients having one or more MET ± CRC (adjusted odds ratio [aOR] 4.04, 95% confidence interval [CI] 2.96–5.52), and those having one or more CRC without MET (aOR 2.22, 95% CI 1.68–2.93), were more likely to die in adjusted analysis. Patients who required a MET ± CRC were more likely to be placed in a high-care residential facility (aOR 1.52, 95% CI 1.03–2.24), as were patients who required a CRC without MET (aOR 1.61, 95% CI 1.22–2.14). The LOS of patients who required a MET ± CRC, and CRC without MET, was longer than that of patients who required neither (P < 0.001). Conclusions: Both MET and CRC were associated with increased likelihood of death and new residential facility placement, after adjusting for factors such as age, comorbidity, and frailty. These data are important for patient prognostication, discussions on goals of care, and discharge planning. The high death rate of patients requiring a CRC (without a MET) has not been previously reported, and may suggest that CRCs among older inpatients should be expediated and attended by senior medical personnel. [ABSTRACT FROM AUTHOR]

Background: Modifications to rapid response team (RRT) activation criteria occur commonly in Australian hospitals without evidence to define their use. Aims: To evaluate the effectiveness of RRT activation criteria modifications in preventing RRT activation and differences in adverse events associated with treatment delays caused by modifications. Methods: A prospective chart audit of hospital patients with RRT activation criteria modifications admitted during a 12‐month period in a large regional hospital in Toowoomba, Australia. The incidence of RRT activation criteria modifications, RRT activations and rates of adverse events following criteria modifications were investigated. Adverse events were defined as a delayed treatment on the ward, unplanned intensive care unit admission, cardiac arrest and unexpected death. Differences in patient outcomes among medical and surgical patients were also investigated. Results: A total of 271 patients out of 4009 admitted patients had modifications to their RRT activation criteria. There was no difference in rates of RRT activation in patients with modified criteria compared with patients with unmodified criteria (P = 0.37). In patients with RRT activation criteria modifications, rates of adverse events were higher in patients who met their modified RRT criteria (93.3%) compared with those who did not meet modified RRT criteria (3.8%; P < 0.001). Additionally, in patients with modifications, rates of adverse events were higher in medical patients (27.6%; n = 50) compared with surgical patients (15.6%; n = 14; P = 0.03). Conclusions: The results strongly suggest that RRT criteria modification is associated with no difference in rates of RRT activation and with detrimental impacts on patient safety, particularly in medical patients. [ABSTRACT FROM AUTHOR]

Rapid reponse teams emerged 27 years ago to identify deteriorating patients and reduce preventable harm. There are concerns that such teams have deskilled hospital staff. However, over the past 20 years, there have been marked changes in hospital care and workplace requirements for hospital staff. In this article, we contend that hospital staff have been reskilled rather than deskilled. [ABSTRACT FROM AUTHOR]

Background: Rapid Response Teams (RRTs) help in the early recognition of deteriorating patients in hospital wards, and provide the needed management at the bedside by a qualified team. Aim of the Work: To describe the characteristics of the RRT calls in a tertiary hospital in Egypt. Patients and Methods: A prospective cohort study for a one-year duration from January 2021 till December, 2021was conducted, during this period a total of 2338 patients were reviewed, and 34 RRT calls were recorded. Results: Our results showed that 10 calls (63%) of Rapid Response Team calls were in the daytime, and Nurses were the main activators with 27 activations (90%). Modified Early Warning scoring system (MEWS) and Pediatric Early Warning Score (PEWS) used were the main cause of RRT activation with a total of (66.7%), the majority of cases didn't refer to the Intensive Care Unit (ICU), 19 patients stay in the ward (76%) and 22 cases (100%) were recovered. Conclusion: More than half of RRT calls were in the daytime, and nurses were the main activators. Most rapid response team activations involve relatively few interventions, patient-activated RRT should consider as a patient right in the future, and further studies showed be conducted to evaluate the best effective methods for applying RRT among different health care facilities. [ABSTRACT FROM AUTHOR]

Emergency cesarean section is one of the most critical methods in the treatment of high-risk emergency obstetric cases. The aim of this study was to explore the clinical effect of constructing a Rapid Response Team (RRT) in emergency cesarean section. This is a pre- and post-implementation study. The patients who underwent emergency cesarean section were retrospectively analyzed and divided into an experimental group and a control group. There were 52 patients (June–December 2020) in the control group who underwent routine emergency cesarean section without an RRT, and 51 patients (January–June 2021) in the experimental group who underwent emergency cesarean section with an RRT. The operation time indexes (DOI, decision-to-operating room interval; O-I, operating room-to-incision interval; DII, decision-to-incision interval; I-D, incision-to-delivery interval; DDI, decision-to-delivery interval), DDI pass rate, neonatal Apgar score and maternal complications in the two groups were compared. Moreover, the management time trends (DOI, DII, and DDI) in the experimental group were analyzed. The DDI, DII, DOI, and O-I of the experimental group were shorter than those of the control group, and the differences were significant (p < 0.05). The DDI pass rate in the experimental group was higher than that in the control group, and the difference was significant (p < 0.01). The 1-min Apgar score of the experimental group was higher than that of the control group (p < 0.05). The key intervals of emergency cesarean section in the experimental group leveled off after approximately 3 to 4 months. In the face of emergency situations, the implementation of an emergency cesarean section RRT can improve delivery intervals for emergency cesarean and would be conducive to maternal and infant safety. [ABSTRACT FROM AUTHOR]

Background: Medical emergency teams (METs) have been implemented to reduce hospital mortality by the early recognition and treatment of potentially life-threatening conditions. The objective of this study was to establish a clinically useful association between clinical variables and mortality risk, among patients assessed by the MET, and further to design an easy-to-use risk score for the prediction of death within 30 days. Methods: Observational retrospective register study in a tertiary university hospital in Sweden, comprising 2,601 patients, assessed by the MET from 2010 to 2015. Patient registry data at the time of MET assessment was analysed from an epidemiological perspective, using univariable and multivariable analyses with death within 30 days as the outcome variable. Predictors of outcome were defined from age, gender, type of ward for admittance, previous medical history, acute medical condition, vital parameters and laboratory biomarkers. Identified factors independently associated with mortality were then used to develop a prognostic risk score for mortality. Results: The overall 30-day mortality was high (29.0%). We identified thirteen factors independently associated with 30-day mortality concerning; age, type of ward for admittance, vital parameters, laboratory biomarkers, previous medical history and acute medical condition. A MET risk score for mortality based on the impact of these individual thirteen factors in the model yielded a median (range) AUC of 0.780 (0.774–0.785) with good calibration. When corrected for optimism by internal validation, the score yielded a median (range) AUC of 0.768 (0.762–0.773). Conclusions: Among clinical variables available at the time of MET assessment, thirteen factors were found to be independently associated with 30-day mortality. By applying a simple risk scoring system based on these individual factors, patients at higher risk of dying within 30 days after the MET assessment may be identified and treated earlier in the process. [ABSTRACT FROM AUTHOR]

Background: Medical emergency teams (METs) have been implemented to reduce hospital mortality by the early recognition and treatment of potentially life-threatening conditions. The objective of this study was to establish a clinically useful association between clinical variables and mortality risk, among patients assessed by the MET, and further to design an easy-to-use risk score for the prediction of death within 30 days. Methods: Observational retrospective register study in a tertiary university hospital in Sweden, comprising 2,601 patients, assessed by the MET from 2010 to 2015. Patient registry data at the time of MET assessment was analysed from an epidemiological perspective, using univariable and multivariable analyses with death within 30 days as the outcome variable. Predictors of outcome were defined from age, gender, type of ward for admittance, previous medical history, acute medical condition, vital parameters and laboratory biomarkers. Identified factors independently associated with mortality were then used to develop a prognostic risk score for mortality. Results: The overall 30-day mortality was high (29.0%). We identified thirteen factors independently associated with 30-day mortality concerning; age, type of ward for admittance, vital parameters, laboratory biomarkers, previous medical history and acute medical condition. A MET risk score for mortality based on the impact of these individual thirteen factors in the model yielded a median (range) AUC of 0.780 (0.774–0.785) with good calibration. When corrected for optimism by internal validation, the score yielded a median (range) AUC of 0.768 (0.762–0.773). Conclusions: Among clinical variables available at the time of MET assessment, thirteen factors were found to be independently associated with 30-day mortality. By applying a simple risk scoring system based on these individual factors, patients at higher risk of dying within 30 days after the MET assessment may be identified and treated earlier in the process. [ABSTRACT FROM AUTHOR]

Background: Approximately one-third of rapid response teams (RRT) involve end-oflife care (EOLC) issues. Intensive care unit (ICU) registrar experience in such calls is underinvestigated. Aims: To evaluate the proportion of RRT calls triaged as relating to EOLC issues, issues around communication regarding prognostication, registrar self-reported moral distress and associations between RRT EOLC classification and patient outcomes. Methods: Prospective observational study of RRT calls in a tertiary referrals hospital between December 2016 and January 2017 using a standardised case report form and data from an electronic RRT database. Results: There were 401 RRT calls in the study period, and data were available for 270 (67%) calls, of which 72%, 10% and 18% were triaged as ‘obviously not EOLC call’, ‘obvious EOLC call’ and ‘uncertain EOLC call’ respectively. Most discussions regarding prognostication occurred between registrars, and more than half (55%) were with a covering doctor. Consensus on prognostication was achieved in 93% cases. Registrars reported distress in 19% of calls that obviously related to EOLC and 22% of calls that were uncertain, compared with <1% of calls that were obviously not relating to EOLC. Inhospital mortality was 6%, 67% and 39% for obviously not EOLC, obvious EOLC and uncertain EOLC calls respectively. Conclusions: EOLC issues occur commonly in RRT calls and are often associated with moral distress to ICU registrars. Although consensus on prognostication is usually achieved, conversations often involve covering doctors. These issues impact on the ICU registrar experience of RRT calls and require further exploration. [ABSTRACT FROM AUTHOR]

Prior studies analyzing patient experience with noninvasive ventilation (NIV) found the most impactful interaction that patients remembered was with nurses, however a survey of nurses regarding the management of patients treated with NIV has shown that most nurses felt unprepared to care for these sick patients. Our qualitative descriptive study explored the current nursing experience using NIV as a treatment for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Nine (n = 9) subject matter expert nurses practicing in a variety of clinical settings participated in semi‐structured interviews. The COnsolidated criteria for REporting Qualitative research checklist was followed for interview development. Interview transcripts were subsequently analyzed using deductive thematic analysis. Themes identified from the interviews pertained to patient assessment, novice nurses' need for clinical support, team communication, and nursing education. Improving interprofessional team communication and collaboration skills, and implementing guidelines for NIV utilization were specified as essential components of NIV education for nurses. Even though the nursing role in the care of AECOPD NIV patient could be institution dependent, the themes presented in our study are useful in identifying opportunities for NIV nursing education and areas for further research. Patient or Public Contribution: Nurses served as interviewees for this study. [ABSTRACT FROM AUTHOR]

The article introduces the Patient Vigilance System (PVS) to reduce rapid response system (RRS) calls and improve patient care planning, demonstrating that the PVS significantly increased the proportion of patients with clinical plans after RRS calls.

In view of the shortage of medical staff, the quality and continuity of care may be improved by employing advanced practice providers (APPs). This study aims to assess the quality of these APPs in critical care. In a large teaching hospital, rapid response team (RRT) interventions led by APPs were assessed by independent observers and intensivists and compared to those led by medical residents MRs. In addition to mortality, the MAELOR tool (assessment of RRT intervention), time from RRT call until arrival at the scene and time until completion of clinical investigations were assessed. Process outcomes were assessed with the crisis management skills checklist, the Ottawa global rating scale and the Mayo high-performance teamwork scale. The intensivists assessed performance with the handoff CEX recipient scale. Mortality, MAELOR tool, time until arrival and clinical investigation in both groups were the same. Process outcomes and performance observer scores were also equal. The CEX recipient scores, however, showed differences between MRs and APPs that increased with experience. Experienced APPs had significantly better situational awareness, better organization, better evaluations and better judgment than MRs with equal experience (p < 0.05). This study shows that APPs perform well in leading an RRT and may provide added quality over a resident. RRTs should seriously consider the deployment of APPs instead of junior clinicians. [ABSTRACT FROM AUTHOR]

Copyright of Turkish Journal of Intensive Care is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Delayed transfer to the intensive care unit (ICU) contributes to increased mortality. Clinical tools, developed to shorten this delay, are especially useful in hospitals where the ideal healthcare provider-to-patient ratio is not met. This study aimed to validate and compare the accuracy of the well-accepted modified early warning score (MEWS) and the newer cardiac arrest risk triage (CART) score in the Philippine setting. Patients and methods: This case-control study involved 82 adult patients admitted to the Philippine Heart Center. Patients who had cardiopulmonary (CP) arrest at the wards and those transferred to the ICU were included. Vital signs and alert-verbal-pain-unresponsive (AVPU) scales were recorded from recruitment until 48 hours prior to CP arrest or ICU transfer. The MEWS and CART scores were computed at specific time points and compared using measures of validity. Results: The highest accuracy was obtained by the CART score with a cut-off of ≥12 at 8 hours prior to CP arrest or ICU transfer, with a specificity of 80.43% and sensitivity of 66.67%. At this time point, the MEWS with a cut-off of ≥3 had a specificity of 78.26% but a lower sensitivity of 58.33%. The area under the curve (AUC) analysis revealed that these differences were not statistically significant. Conclusion: We recommend an MEWS threshold of 3 and a CART score threshold of 12 to help identify patients at risk for clinical deterioration. The CART score had comparable accuracy to the MEWS, but the latter's computation may be easier. [ABSTRACT FROM AUTHOR]

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In March 2021, Lao People's Democratic Republic (Laos) reported an avian influenza A(H5N6) virus infection in a 5‐year‐old child identified through sentinel surveillance. This was the first human A(H5N6) infection reported outside of China. A multidisciplinary investigation undertook contact tracing and enhanced human and animal surveillance in surrounding villages and live bird markets. Seven Muscovy ducks tested positive for highly pathogenic avian influenza A(H5N6) viruses. Sequenced viruses belonged to clade 2.3.4.4h and were closely related to viruses detected in poultry in Vietnam and to previous viruses detected in Laos. Surveillance and coordinated outbreak response remain essential to global health security. [ABSTRACT FROM AUTHOR]

Background: Information about the epidemiology of older Internal Medicine patients receiving medical emergency team (MET) calls is limited. We assessed the prevalence, characteristics, risk factors, and outcomes of this vulnerable group. Methods: Internal Medicine patients aged >75 years who were admitted via the Emergency Department to a tertiary hospital between January 2015 to December 2018 and who activated a MET call were compared to patients without MET call activation during the same time period. Outcome measures included management post‐MET call, Intensive Care Unit (ICU) admission rates, discharge disposition, length of hospital stays (LOS), and in‐patient mortality. Results: There were 10,803 Internal Medical admissions involving 10,423 patients; median age 85 (IQR 81–89) years. Of these, 995 (10%) patients received at least one MET call. MET call patients had greater physiological instability in the Emergency Department and higher median Charlson comorbidity index values (2, IQR 1–3 vs. 1, IQR 0–2; p <.0001) than non‐MET call patients. Overall, 10% of MET call patients were admitted to ICU. MET patients had a longer median length of stay (9 [IQR 5–14] vs. 4 days [IQR 2–7]; p <.001) and higher in‐hospital mortality (29% vs. 7%; p <.001). However, mortality of MET call patients without treatment limitations was 48/357 (13%). Conclusion: One in ten Internal Medicine patients aged >75 years and admitted via ED had a MET call. Physiological instability in ED and comorbidities were key risk factors. Mortality in MET patients approached 30%. These data can help predict at‐risk patients for improving goals of care and pre‐MET interventions. [ABSTRACT FROM AUTHOR]

Background: The utilization of a rapid response team (RRT) has influenced the clinical outcomes of patients in the general ward. However, the characteristics of RRT-screened patients who are transferred to the intensive care unit (ICU) are unknown. Therefore, the present study aimed to evaluate these factors.Methods: We conducted a retrospective study using patient data from a tertiary medical center in Republic of Korea between January 2016 and December 2017. Multivariate logistic regression analyses were performed to assess the factors associated with the risk of in-hospital mortality.Results: A total of 1,096 patients were included: 389 patients were transferred to the ICU, and 707 patients stayed in the ward. Patients in the ICU group were more likely to be admitted for medical reasons, hepatobiliary disease, and high heart rate. More interventions were performed, hospital stays were longer, and the 28-day and in-hospital mortality rates were higher in the ICU group than in the ward group. Multivariate logistic regression analyses showed that risk factors affecting ICU admission were higher Sequential Organ Failure Assessment (SOFA) score, National Early Warning Score (NEWS), platelet count, and lactate level. ICU transfer was not associated with in-hospital mortality.Conclusions: Among RRT-screened patients, those with higher SOFA score, NEWS, and lactate level were more likely to be transferred to the ICU. Therefore, these patients should be closely monitored and considered for ICU transfer. [ABSTRACT FROM AUTHOR]

Pulmonary embolism response teams (PERT) aim to improve treatment of acute pulmonary embolism (PE). PERT focus on intermediate- and high-risk PE patients, but recent multicenter studies show that low-risk PE patients compose one in five of all PERT cases. Conversely, not all intermediate- and high-risk PE patients elicit a PERT activation. The factors leading to PERT activations remain unknown. This study aims to describe the patient characteristics associated with PERT activation for low-risk PE patients and characteristics precluding PERT activation for intermediate/high-risk PE patients. We analysed data from all patients with confirmed PE diagnosed in the Massachusetts General Hospital Emergency Department from August 2013 to February 2017 and cross-referred these data with patients who received a PERT activation and patients who did not. Patients were stratified into low-risk or intermediate/high-risk PE. Univariate analyses were performed within each risk group comparing patients with a PERT activation and patients without. Fifteen percent (56/374) of low-risk PE patients triggered a PERT activation. Patient characteristics associated with PERT activation were: (1) vascular disease, (2) pulmonary diseases, (3) thrombophilia, (4) current use of anticoagulants, (5) central PE and (6) concurrent DVT. Thirty-five percent (110/283) of intermediate/high-risk PE patients did not elicit a PERT activation. Patient characteristics precluding a PERT activation were: (1) vascular disease, (2) malignancies and (3) asymptomatic presentation. Low-risk PE patients with PERT activations had more extensive clot burden, complex comorbidities, or had failed anticoagulation treatment. Intermediate/high-risk PE patients without PERT activations tended to have malignancies or vascular disease. [ABSTRACT FROM AUTHOR]

Sporadic outbreak of African swine fever (ASF) is still been reported in Nigeria. There is a paucity of information on the lessons learnt in the control of ASF in Ebonyi State, Nigeria. The purpose of this study was to describe the outbreak response to ASF, identify possible risk factors for the outbreak of ASF, and describe strategies for control of ASF in Ebonyi State, with a view to provide information necessary for public health action. We carried out a retrospective/prospective disease investigation by reviewing case reports of outbreaks of ASF in Ebonyi State between 1st January-30th June 2021, from the Department of Veterinary Services, Federal Ministry of Agriculture and Rural Development (FDVS), Ebonyi State, Nigeria. We defined the case definition for a suspected case of ASF, constituted a Rapid Response Team (RRT). Prospective outbreak investigation was conducted by reviewing farm records on sales of pigs to other pig farms. Sample collected include tissue section (spleen, lungs, liver), whole blood (without anticoagulant) at 4-5°C stored in Giostyle, for onward transport to the National Veterinary Research Institute, (NVRI) Jos for Laboratory diagnosis. On the 28th through 30th of April 2021 suspected outbreak of ASF was reported at Izzi Local Government Area (LGA) of Ebonyi State, herd size of 400 pigs. Affected pigs showed marked erythema, Ataxia, acute mortality, respiratory distress. On the 14thof May 2021, the Laboratory sample was confirmed as positive for African swine fever virus (ASFV). Risk factors identified during outbreak investigation were; poor drainages within and between pens, feed sources were mainly agricultural waste products sourced from (poultry, market, livestock), poor biosecurity measures; foot deep, appear not to be in use and poor choice of disinfectants. The need to maintain biosecurity measures within the farm can never be overemphasized. A sporadic outbreak of ASF may occur when there is a breach in the biosafety protocol of a pig production system. Consequently, we discourage feeding poultry waste to pigs, ensure proper drainages within and between pens, use recommended disinfectants. Furthermore, the State Ministry of Agriculture should develop a minimum operating standard for would be pig farmers in the state to ensure biosecurity standards, and supervised compliance before permission is granted for the operation of a pig farms within the state. [ABSTRACT FROM AUTHOR]

Background: Rapid response systems (RRSs) are essential components of patient safety systems; however, limited evidence exists regarding their effectiveness and optimal structures. We aimed to assess the activation patterns and outcomes of RRS implementation with/without a real-time automatic alerting system (AAS) based on electronic medical records (EMRs). Methods: We retrospectively analyzed clinical data of patients for whom the RRS was activated in the surgical wards of a tertiary university hospital. We compared the code rate, in-hospital mortality, unplanned intensive care unit (ICU) admission, and other clinical outcomes before and after applying RRS and AAS as follows: pre-RRS (January 2013–July 2015), RRS without AAS (August 2015–November 2016), and RRS with AAS (December 2016–December 2017). Results: In-hospital mortality per 1000 admissions decreased from 15.1 to 12.9 after RRS implementation (p < 0.001). RRS activation per 1000 admissions increased from 14.4 to 26.3 after AAS implementation. The severity of patients' condition calculated using the modified early warning score increased from 2.5 (± 2.1) in the RRS without AAS to 3.6 (± 2.1) (p < 0.001) in the RRS with AAS. The total and preventable code rates and in-hospital mortality rates were comparable between the RRS implementation periods without/with AAS. ICU duration and mortality results improved in patients with RRS activation and unplanned ICU admission. The data of RRS non-activated group remained unaltered during the study. Conclusions: Real-time AAS based on EMRs might help identify unstable patients. Early detection and intervention with RRS may improve patient outcomes. [ABSTRACT FROM AUTHOR]

Sepsis carries a high mortality in the United States. Hospitals across the country are working to find new ways to recognize, treat, and streamline care for patients with sepsis. At an academic medical center in the Midwest, a quality improvement project was developed using a sepsis rapid response team with physician associates/assistants (PAs) and NPs. This improved hospital adherence to sepsis evaluation and order set use from 48% to 86%. The added evaluation of the patient by a PA or NP, along with ensuring adherence to the sepsis order set, made an effective first step to improve care of patients with sepsis in this hospital. [ABSTRACT FROM AUTHOR]

This study describes the apparent discontinuation of cholera transmission in Haiti since February 2019. Because vulnerabilities persist and vaccination remains limited, our findings suggest that case-area targeted interventions conducted by rapid response teams played a key role. We question the presence of environmental reservoirs in Haiti and discuss progress toward elimination. [ABSTRACT FROM AUTHOR]

Background and Objectives: For effective function of the rapid response system (RRS), prompt identification of patients at a high risk of cardiac arrest and RRS activation without hesitation are important. This study aimed to identify clinical factors that increase the risk of intensive care unit (ICU) transfer and cardiac arrest to identify patients who are likely to develop serious conditions requiring ICU management and appropriate RRS activation in Japan. Materials and Methods: We performed a single-center, case control study among patients requiring a rapid response team (RRT) call from 2017 to 2020. We extracted the demographic data, vital parameters, blood oxygen saturation (SpO2 ) and the fraction of inspired oxygen (FiO2 ) from the medical records at the time of RRT call. The patients were divided into two groups to identify clinical signs that correlated with the progression of clinical deterioration. Patient characteristics in the two groups were compared using statistical tests based on the distribution. Receiver operating characteristic (ROC) curve analysis was used to identify the appropriate cut-off values of vital parameters or FiO2 that showed a significant difference between-group. Multivariate logistic regression analysis was used to identify patient factors that were predictive of RRS necessity. Results: We analyzed the data of 65 patients who met our hospital’s RRT call criteria. Among the clinical signs in RRT call criteria, respiratory rate (RR) (p < 0.01) and the needed FiO2 were significantly increased (p < 0.01) in patients with severe disease course. ROC curve analysis revealed RR and needed FiO2 cut-off values of 25.5 breaths/min and 30%. The odds ratio for the progression of clinical deterioration was 40.5 times higher with the combination of RR ≥ 26 breaths/min and needed FiO2 ≥ 30%. Conclusions: The combined use of RR ≥ 26 breaths/min and needed FiO2 ≥ 30% might be valid for identifying patients requiring intensive care management. [ABSTRACT FROM AUTHOR]

Background: Despite international standards for recognition and response to deterioration, warning signs are not always identified by staff on acute hospital wards. Patient and family‐initiated escalation of care schemes have shown some benefit in assisting early recognition, but are not widely used in many clinical practice areas. Objectives: To explore (a) patients' and relatives' experiences of acute deterioration and (b) patients', relatives' and healthcare professionals' perceptions of the barriers or facilitators to patient and family‐initiated escalation of care in acute adult hospital wards. Methods: We conducted a qualitative review using Cochrane methodology. Two reviewers independently screened studies, extracted data, and appraised the quality using a qualitative critical appraisal tool. Findings were analysed using thematic synthesis and confidence in findings was assessed using GRADE‐CERQual. Search strategy: MEDLINE, CINAHL, EMBASE, PsychINFO databases and grey literature from 2005 to August 2019. Inclusion criteria: Any research design that had a qualitative element and focused on adult patients' and relatives' experiences of deterioration and perceptions of escalating care. Results: We included five studies representing 120 participants and assessed the certainty of evidence as moderate using GRADE‐CERQual. Findings indicated that a number of patients/relatives have the ability to detect acute deterioration, however, various factors act as both barriers and facilitators to being heard. These include personal factors, perceptions of role, quality of relationships with healthcare staff, and organisational factors. Theoretical understanding suggests that patient and relative involvement in escalation is dependent on both inherent capabilities and the factors that influence empowerment. Conclusion: This review highlights that patient and family escalation of care interventions need to be designed with the aim of improving patient/relative—clinician collaboration and the sharing of responsibility. Relevance to practice: These factors need to be addressed to promote more active partnerships when designing and implementing patient and family‐initiated escalation of care interventions. [ABSTRACT FROM AUTHOR]

Background: The Adult Deterioration Detection System for Medical Emergency Team (MET) activation is widely used and includes single parameter (SP‐MET) and multiple parameter (MP‐MET) disturbances. Whether the patient characteristics, interventions and outcomes differ for SP‐MET compared with MP‐MET is uncertain. Aims: To describe MET interventions and outcomes of SP versus MP MET in the Acute Medical Unit (AMU) of a tertiary care hospital. Methods: Retrospective audit over 6 months comparing SP‐MET and MP‐MET groups. Results: SP‐MET constituted 64.1% (168) of 262 AMU MET calls, most commonly for hypotension (35.5%) and tachycardia (14.1%). There were no significant differences in demographic and disease characteristics between the two groups. Common interventions included fluid/electrolyte replacement in 139 (52%), oxygen therapy in 46 (17%) and non‐invasive ventilation in 33 (13%) patients. After MET intervention, 82.4% patients stayed on the ward, 8.4% died/were palliated, 6.5% were transferred to the Intensive Care Unit (ICU) and 2.7% patients required urgent transfer to the theatre for intervention. SP‐MET patients were more likely to remain on the ward (88.7% vs 71.3%; P = 0.001), receive ward‐based interventions (85.1% vs 61.7%; P < 0.001) and less likely to experience death/palliation (4.2% vs 16%, P = 0.001) compared with the MP‐MET group. MP‐MET were independently associated with negative outcomes (OR 3.10; 95% CI 1.60–6.00). Conclusion: SP‐MET identify a cohort of patients at lower risk of requiring escalation of care and ICU admission. Given the resource intensity of MET activation, further research is warranted to determine whether alternative response strategies are appropriate for selected SP disturbances. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the course of a community gastroenteritis outbreak by Salmonella and implement interventional activities and roles to prevent occurring such an outbreak in the future. Methods: From August 27 to 2 September 2015, 101 individuals were reported among a local community. All affected individuals had a history of food consumption at a local restaurant. A rapid response team conducted active surveillance and interview with the affected individuals and workers of the restaurant. Food items and stools from food handlers and affected individuals were cultured and sent for genotyping. An environmental audit of the restaurant had been conducted. Results: The total majority of the affected individuals were male and more than 70% belonged to the young age group from 15 to 45 years. Out of the total, 97% had diarrhea, 70% fever, 56% abdominal cramps and 49% vomiting. All those affected were managed symptomatically except for 14 cases admitted for intravenous rehydration. Breakdown of food safety and basic personal hygiene were detected in the environment of the restaurant and among the workers. There are 39 out of 49 stool cultures of cases, six out of 18 food handlers, and five food samples were positive for Salmonella spp. The identical DNA fingerprinting pattern among S. Weltevreden strains originating from human cases and food was detected. Conclusion: This is the first reported community foodborne of S. Weltevreden outbreak in Oman. The importance of food safety and rigors environmental safety is emphasized. Basic personal hygiene and training of food handlers in restaurants are recommended with public health measurements. [ABSTRACT FROM AUTHOR]

Background: Assessing and managing the risk of clinical deterioration is a cornerstone of emergency care, commencing at triage and continuing throughout the emergency department (ED) care. The aim of this scoping review was to assess the extent, range and nature of published research related to formal systems for recognising and responding to clinical deterioration in emergency department (ED) patients. Materials and methods: We conducted a scoping review according to PRISMA-ScR guidelines. MEDLINE complete, CINAHL and Embase were searched on 07 April 2021 from their dates of inception. Human studies evaluating formal systems for recognising and responding to clinical deterioration occurring after triage that were published in English were included. Formal systems for recognising and responding to clinical deterioration were defined as: i) predefined patient assessment criteria for clinical deterioration (single trigger or aggregate score), and, or ii) a predefined, expected response should a patient fulfil the criteria for clinical deterioration. Studies of short stay units and observation wards; deterioration during the triage process; system or score development or validation; and systems requiring pathology test results were excluded. The following characteristics of each study were extracted: author(s), year, design, country, aims, population, system tested, outcomes examined, and major findings. Results: After removal of duplicates, there were 2696 publications. Of these 33 studies representing 109,066 patients were included: all were observational studies. Twenty-two aggregate scoring systems were evaluated in 29 studies and three single trigger systems were evaluated in four studies. There were three major findings: i) few studies reported the use of systems for recognising and responding to clinical deterioration to improve care of patients whilst in the ED; ii) the systems for recognising clinical deterioration in ED patients were highly variable and iii) few studies reported on the ED response to patients identified as deteriorating. Conclusion: There is a need to re-focus the research related to use of systems for recognition and response to deteriorating patients from predicting various post-ED events to their real-time use to improve patient safety during ED care. [ABSTRACT FROM AUTHOR]

Purpose: We sought to evaluate if incorporating an early warning system (EWS), the Visensia Safety Index (VSI) and the National Early Warning Systems 2 (NEWS2), may lead to earlier identification of rapid response team (RRT) patients. Methods: This was a retrospective study (2015-2018) of patients experiencing RRT activation within a tertiary care network. We evaluated the proportion of patients with an EWS alert prior to RRT activation and their associated outcomes (primary: hospital mortality). Results: There were 6,346 RRT activations over the study period. Of these, 2042 (50.8%) patients would have had a VSI alert prior to RRT activation, with a median advanced time of 3.6 (IQR 0.5-12.8) hours, compared to 2351 (58.4%) patients and 9.8 (IQR 2.0-18.7) hours for NEWS2. Patients with a potential alert prior to RRT activation had an increased odds of mortality for both VSI (OR 1.2, 95%CI 1.1-1.3) and NEWS2 (OR 2.7, 95% CI 2.4-3.1). Prognostic accuracy for hospital mortality was similar between groups. Conclusion: Utilization of an EWS by an RRT has potential to provide earlier recognition of deterioration and mortality risk among hospitalized inpatients. [ABSTRACT FROM AUTHOR]

Background: Despite wide implementation of rapid response teams (RRTs), no published data exist on RRT nurses' attitudes and barriers to the rapid response system (RRS). Methods: We piloted a 5‐point Likert‐type scale questionnaire among all Finnish university hospitals' RRT nurses with optional open‐ended comments. The impact of more frequent RRT participation was further investigated. Results: The response rate was 46% (n = 176/379, 34%‐93% between hospitals). The respondents median experience on a RRT was three years (0.8‐5) and median participation was two (1˗5) RRT activations per month. Over 90% of the RRT nurses felt that RRS prevented cardiac arrests and improved patient safety. Nurses with five or more RRT activations/month believed their critical care skills had improved through these duties (94% vs 71%, P =.001), considered their RRT work meaningful (94% vs 76%, P =.005) and wanted to continue as RRT nurses (91% vs 74%, P =.015) more often than nurses with less than five RRT activations/month. In addition to the infrequent RRT participation, further negative experiences with RRS among the RRT nurses included feeling overworked (68%) or undercompensated (94%) for the RRT duties and conflicts between RRT and ward doctors (25%). Conclusion: RRT nurses consider their work important and believe it fosters improved critical care skills; these beliefs are emphasized among those with more frequent RRT participation. Infrequent RRT participation, feeling overworked and/or undercompensated and conflicts between RRT and ward doctors may present barriers for successful RRS among RRT nurses. [ABSTRACT FROM AUTHOR]

Background: In Japan, 44.3% of neonates are delivered in private clinics without an attending pediatrician. Obstetricians in the clinics must resuscitate asphyxiated neonates in unstable condition, such as respiratory failure, and they are frequently transferred to tertiary perinatal medical centers. There has been no study comparing the physiological status and prognosis of neonates transported by ambulance with those transported by helicopter. Methods: Medical and transport records were used to compare the physiological status of neonates transported to Kagoshima City Hospital by land and those transported by air between January 1, 2013, and December 31, 2017. Results : Data from 425 neonates transferred by land and 143 by air were analyzed. There were no significant differences between the two groups in mean gestational age, mean birthweight, fetal blood pH, Apgar score, or the Score for Neonatal Acute Physiology with Perinatal Extension‐II (SNAPPE‐II) on arrival to the tertiary center (16.3 ± 15.4 [95% confidence interval (CI): 13.2–17.7] vs 16.4 ± 15.4 [95% CI: 13.9–19.0], respectively; P = 0.999); both groups had SNAPPE‐II score 10–19, indicating no difference in mortality risk. The times to starting first aid and to admission to the intensive care unit were significantly reduced in neonates transported by air than by land. In subgroup analysis of patients of a gestational age ≤28 weeks, all cases of severe intraventricular hemorrhage (IVH) were observed in the land transportation group. Conclusions: Neonatal transportation by air is as safe as land transportation, and time to first aid and intensive care are significantly reduced by transportation by air than by land. Air transport could also contribute to the prevention of IVH in neonatal transportation. [ABSTRACT FROM AUTHOR]

Background: The NSW Clinical Excellence commission introduced the 'Between the Flags' programme, in response to the death of a young patient, as a system‐wide approach for early detection and management of the deteriorating patient in all NSW hospitals. The impact of BTF implementation on the 35 larger hospitals with intensive care units (ICU) has not been reported previously. Aim: To assess the impact of 'Between the Flags' (BTF), a two‐tier rapid response system across 35 hospitals with an ICU in NSW, on the incidence of in‐hospital cardiac arrests and the incidence and outcome of patients admitted to an ICU following cardiac arrest and rapid response team activation. Methods: This is a prospective observational study of the BTF registry (August 2010 to June 2016) and the Australian and New Zealand Intensive Care Society Adult Patient Database (January 2008 to December 2016) in 35 New South Wales public hospitals with an ICU. The primary outcome studied was the proportion of in‐hospital cardiac arrests. Secondary outcomes included changes in the severity of illness and outcomes of cardiac arrest admissions to the ICU and changes in the volume of rapid response calls. Results: The cardiac arrest rate per 1000 hospital admissions declined from 0.91 in the implementation period to 0.70. Propensity score analysis showed significant declines in ICU and hospital mortality and length of stay for cardiac arrest patients admitted to the ICU (all P < 0.001). Conclusions: The BTF programme was associated with a significant reduction in cardiac arrests in hospitals and ICU admissions secondary to cardiac arrests in 35 NSW hospitals with an ICU. [ABSTRACT FROM AUTHOR]

Background: Rapid response teams are intended to improve early diagnosis and intervention in ward patients who develop acute respiratory or circulatory failure. A management protocol including the use of a handheld ultrasound device for immediate point-of-care ultrasound (POCUS) examination at the bedside may improve team performance. The main objective of the study was to assess the impact of implementing such a POCUS-guided management on the proportion of adequate immediate diagnoses in two groups. Secondary endpoints included time to treatment and patient outcomes.Methods: A prospective, observational, controlled study was conducted in a single university hospital. Two teams alternated every other day for managing in-hospital ward patients developing acute respiratory and/or circulatory failures. Only one of the team used an ultrasound device (POCUS group).Results: We included 165 patients (POCUS group 83, control group 82). Proportion of adequate immediate diagnoses was 94% in the POCUS group and 80% in the control group (p = 0.009). Time to first treatment/intervention was shorter in the POCUS group (15 [10-25] min vs. 34 [15-40] min, p < 0.001). In-hospital mortality rates were 17% in the POCUS group and 35% in the control group (p = 0.007), but this difference was not confirmed in the propensity score sample (29% vs. 34%, p = 0.53).Conclusion: Our study suggests that protocolized use of a handheld POCUS device at the bedside in the ward may improve the proportion of adequate diagnosis, the time to initial treatment and perhaps also survival of ward patients developing acute respiratory or circulatory failure. Clinical Trial Registration NCT02967809. Registered 18 November 2016, https://clinicaltrials.gov/ct2/show/NCT02967809 . [ABSTRACT FROM AUTHOR]

Background: Rapid response teams (RRT) were first proposed as a means of reducing inpatient morbidity and mortality. Modifying RRT activation triggers poses a potential risk for delayed recognition of a deteriorating patient. Trigger modifications have not been validated for safety. Aims: To determine if RRT trigger modifications are associated with: increased frequency of recurrent RRT activation; increased length of stay (LOS); increased intensive care admission; and increased in‐hospital mortality. Methods: A retrospective audit of all RRT activations occurring at the Launceston General Hospital (LGH) over an 18‐month period was performed. Results: Rate of recurrent RRT activations did not decrease with the use of trigger modifications around the time of RRT activation, and for patients with two modifications, the frequency increased (1.98 vs 1.32, P = 0.007). LGH LOS increased for patients with any trigger modifications compared to those with none (11 vs 9, P = 0.0002), and for patients with two modifications (11.5 vs 9, P = 0.010). Total hospital LOS increased for patients with any modifications compared to patients with none (12 vs 10, P = 0.002). There was no significant association between trigger modifications and frequency of intensive care unit admission. The relative risk of in‐hospital death increased with increasing numbers of trigger modifications (relative risk 1.38–4.89). Conclusions: Trigger modifications are associated with increased hospital LOS and increased rate of in‐hospital death and do not reduce the number of recurrent events. For patients in whom escalation of care is not appropriate, the presence of multiple trigger modifications at the time of an RRT activation may be a useful trigger for conversations around goals of care. [ABSTRACT FROM AUTHOR]

As sepsis is a life-threatening disease, appropriate measures should be started as soon as possible after diagnosis. Duration until first therapy affects survival. However, guideline adherence of primary sepsis care is often low. Dedicated sepsis response teams (SRT) may improve primary sepsis care. PubMed was searched for studies investigating the effect of an implementation of SRTs. This review discusses the results of five studies presenting results before and after implementation of SRTs. The importance of choosing the alert and the right team composition of the SRT is also discussed. Implementing SRTs is associated with a better compliance with guidelines regarding primary sepsis care and with a reduction in hospital mortality. However, scientific evidence of the studies is limited due to chosen study design. SRTs can be a strong method to improve primary sepsis care in specific hospital settings if the pros and cons against the other measures of quality improvement are considered and the technical details such as alerts and team members are customized to the individual hospital setting. [ABSTRACT FROM AUTHOR]

Background: Deterioration after ICU discharge may lead to readmission or even death. Interventions (eg, critical care transition programs) have been developed to improve the clinical handover between the ICU and the ward. We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) according to Cochrane Handbook and Grading of recommendations, assessment, development and evaluations (GRADE) methodology to assess the impact of these interventions on readmission and death (PROSPERO, no CRD42019121746).Methods: We searched PubMed/MEDLINE, CINAHL, AMED, PsycINFO, and the Cochrane Central Register for Controlled Trials from inception until January 2019. We included historically controlled studies that evaluated critical care transition programs in adults discharged from the ICU. Readmission and in-hospital mortality were the primary outcomes. Risk of bias, publications bias, and the quality of evidence were assessed with the ROBINS-Itool, funnel plot and GRADE, respectively.Results: Fifteen observational studies were included (11 in meta-analysis). All studies had at least serious risk of bias. ICU discharge within a critical care transition program modestly reduced the risk of readmission (RR 0.78; 95% CI: 0.64-0.96; TSA-adjusted 95% CI: 0.59-1.03) but not in-hospital mortality (RR 0.82; 95% CI: 0.64-1.06; TSA-adjusted 95% CI: 0.49-1.37). There was substantial heterogeneity among studies. TSA indicated lack of firm evidence. The GRADE quality of evidence on outcomes was very low.Conclusions: We found no clear benefit in terms of reducing risk of readmission or death after ICU discharge, however, with overall very low certainty of evidence. [ABSTRACT FROM AUTHOR]

We sought the role of the hospital inpatient observation and response chart (ORC) in reducing adverse outcomes. We sourced articles written in English and published in PubMed. Track, trigger and response systems can be tiered and use single parameter or aggregate scoring systems; the latter being more prone to error. The documentation and detection of abnormal vital signs can be affected by choice of trigger and response and by ORC design. There is considerable variation in the design of ORC and of rapid response systems (RRS) in general, and this impairs assessment of their efficacy. A high rate of modification of pre‐determined triggers and poor sensitivity of measured outcomes further compromise systematic review. The best‐designed ORC and RRS should optimise the frequency of response team activation to minimise adverse patient outcomes without excess resource utilisation. The role and the risks of electronic data recording are under‐explored. Detecting and responding to deteriorating patients relies upon accurate and clear documentation of vital signs. ORC design and staff education on ORC implementation and usage are integral to minimising ALF and optimising patient outcomes. Standardisation of the design of both the ORC and the hospital RRS are overdue. [ABSTRACT FROM AUTHOR]

An integrative review of the literature specific to leadership within the intensive care unit was planned to guide future research. Four databases were searched. Study selection was based on predetermined inclusion and exclusion criteria and a quality check was done. Data extraction and synthesis involved developing a preliminary thematic coding framework based on a sample of papers. The coding framework and all selected papers were entered into NVivo software. All papers were then coded to the previously identified themes. Themes were summarised and presented with illustrative quotes highlighting key findings. In total, 1102 relevant quotations were coded across the 28 included papers. Four themes pertaining to leadership were described and analysed: (a) leadership dimensions and discourses; (b) leadership experiences; (c) facilitators and/or barriers to leadership; and (d) leadership outcomes. The literature was found to focus on leader behaviours, as well as the leader dimensions of role allocation, clinical and communication skills and traditional hierarchies. Positive behaviours mentioned included good decision-making, staying calm under pressure and being approachable. Leadership experiences (and outcomes) are typically reported to be positive. Personal individual factors seem the biggest enablers and barriers to leadership within the intensive care unit. Training is considered to be a facilitator of leadership within the intensive care unit. This study highlights the current literature on leadership in intensive care medicine and provides a basis for future research on interventions to improve leadership in the intensive care unit. [ABSTRACT FROM AUTHOR]

Introduction: The Rapid Response System for recognising and responding to clinically deteriorating patients has been progressively implemented in acute care hospitals across the globe. This study sought to review the implementation of this system in acute public hospitals in Singapore.Methods: A cross-sectional study using a face-to-face survey questionnaire was conducted.Results: Five out of seven invited hospitals completed the questionnaire and rated the Rapid Response System as either high priority or essential, and indicated its importance over other patient safety indicators. Sensitivity and specificity of the triggering criteria and non-adherence to the escalation protocol were highlighted issues. Only two hospitals had a dedicated response team for providing emergency help to deteriorating ward patients. Limited manpower resources, unclear roles between the primary and response teams, and the potential deskilling of ward staff were reported barriers that inhibited the uptake of a response team. All hospitals had a committee that oversaw its system operation, provided training to ward staff, and used information technology to support the implementation.Conclusion: A variety of approaches have been taken to support the system of recognising and responding to clinical deterioration. This calls for a national approach to enable the standardisation of clinical processes, sharing of educational resources and multi-site evaluation. [ABSTRACT FROM AUTHOR]